The Claims Resolution Specialist is responsible for review and follow up of a client's claim in order to determine the reimbursement that will be provided by the insurance company. The strong willed candidate will be motivated and driven to achieve quality collection results in a timely manner.
Must have Medical Claims Experience
Major Duties and Responsibilities:
Communicates effectively and professionally with the insurance company representatives regarding inquiries on billed claims.
Demonstrates the ability to aggressively collect on accounts receivables.
Demonstrates the ability to identify inconsistent reimbursement and to negotiate repricing on claims.
Negotiates higher reimbursement rates with providers.
Investigates validity of over payments.
Ability to maintain positive relationships and utilize strong customer service skills to expedite payment from providers.
Identifies incorrect claims and assists with correction of these claims.
Provides requested records and documentation to insurance companies in order to process claims efficiently.
Demonstrates understanding of billing revenue codes CPI/ HCPCs and claim forms UB/HCFA.
Demonstrates basic understanding of medical terminology.
Demonstrates understanding of policy deductibles, co pays, coinsurance and out of pocket maximums, out of network deductions and exclusions.
Demonstrates knowledge of diagnosis codes, ICD-10.
Properly documents all communication and follow up that is necessary to collect reimbursement.
Reconciles payments and ensures proper payment amounts have been paid to facility.
Demonstrates knowledge of the claims appeals process.
Demonstrates knowledge of EOB interpretation.
Demonstrates knowledge of the Office Ally and Medisoft billing software.
Communicates effectively with peers and supervisor to address claim issues.
Follows HIPAA Regulations.
Participates in development of Quality Improvement projects.
Follows all practices detailed in the companies Policies and Procedures Manual and Employee Handbook.
Attends and participates in staff meetings and trainings.
Other duties, as assigned.
One year of experience with claims follow up.
HS Diploma. College degree preferred.
Able to share an example of ability to collect large volume in a timely manner.
Able to share an example of ability to communicate and work effectively with their peers and the insurance company representatives.
Ability to work under pressure, multi task, and meet necessary deadlines.
Must have good customer service skills.
Role: Claims Resolution Specialist
Location: San Juan Capistrano,
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