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Claims Resolution Representative

HireTalent

McLean, VA(remote)

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JOB DETAILS
SKILLS
Adjudication, Analysis Skills, Claims Processing, Communication Skills, Computer Skills, Customer Satisfaction, Customer Service Operations, Demographics, Establish Priorities, HIPAA (Health Insurance Portability and Accountability Act), Healthcare, High School Diploma, Leadership, Maintain Compliance, Microsoft Excel, Microsoft Word, Operations Processes, Presentation/Verbal Skills, Pricing, Privacy Controls, Problem Solving Skills, Process Capability, Reimbursement, Research Skills, Team Player, Time Management, Writing Skills
LOCATION
McLean, VA
POSTED
1 day ago
Job Title: Claims Resolution Representative
Job Location: Remote
Job Duration: 6 Months

Job Description:
Job Summary:
  • The Claims Resolution Representative plays a vital role in ensuring accuracy and adherence to the applicable guidelines.
  • This position serves as a crucial liaison between members, providers, agencies, and the internal claims department, demonstrating leadership, collaborative skills, and commitment to achieving results.
  • This position is remote within the United States, but applicants can expect to work Eastern Time regular business hours with some flexibility.

Responsibilities:
  • Independently resolve suspended claims using the resolution screens in accordance with operational procedures and process recoupments.
  • Determine when to use a "Forcible" disposition to override the edit and process the claim based on operational claims adjudication procedure.
  • Review and analyze claims and follow up on the status of claims and reimbursement.
  • Interpret and apply policy and reimbursement rules to support provider inquiries.
  • Ensure accuracy and consistency in claims processing.
  • Research and review submitted claims (electronic) and process them according to policies and procedures.
  • Possess an unwavering commitment to customer service and operational excellence.
  • Perform manual pricing and audit checks to ensure compliance with policies and rules.
  • Review and process suspended claims and submitted documentation.
  • Provide sufficient detail to explain claims denial reasons.
  • Implement workflow processes and capabilities for work queues with the ability to route workstreams.
  • Approve or deny requests for transportation authorization from providers, verify member transportation claims, and process approved claims.
  • Perform manual reviews on claims, documents, and attachments.
  • Release individual claims for providers on review.
  • Independently resubmit claims with applicable corrections.
  • Independently address discrepancies in charges, payments, adjustments, and demographic information.
  • Facilitate manual entry of claims into the system.
  • Review paper claims and attachments, scanning them using scanning equipment to attach the documents to corresponding transaction control numbers.

Other duties as assigned
  • Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.
  • Required Qualifications
  • High School Diploma or GED
  • 1+ years of experience conducting research to resolve issues within the healthcare field

Preferred Qualifications
  • Ability to maneuver through various computer claims and eligibility platforms simultaneously
  • Outstanding customer satisfaction skills
  • Must be firm but professional when interacting with contacts while performing tasks
  • Friendly personality, tact, patience, empathy, and a helpful yet professional attitude are essential
  • Strong computer skills, including proficiency in MS Word and Excel
  • Excellent oral and written communication skills
  • Excellent organization and time management skills, with the ability to establish priorities effectively
  • Ability to read, write, and follow directions
  • Self-directed and capable of working without direct supervision
  • Ability to collaborate effectively with others
  • Create and maintain a positive atmosphere, demonstrating leadership qualities
  • Knowledgeable in claims review and analysis

About the Company

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