Claims Resolution Specialist - Appeals

Overview

As a Claims Resolution Specialist, you will determine the acceptance of providers' payment through claims research, plans, eligibility and notes to determine if the payor owes payment to CareCentrix.

Identifies and escalates provider issues and concerns to the appropriate senior. Works under general supervision. Guides collectors in their performance of invoice processing activities to ensure receivables are reimbursed in an accurate and timely basis. Works directly with the payer, internal and external customers and other contract clients towards efficient and effective collection results. 

Responsibilities

In this role, you will:

• Ensure the coordination of provider invoice activities leading to timely reimbursement of receivables using available resources including databases, internet, and telephone.
• Research and resolve denials received that have not passed payer edits and may lead to a final appeal of denied services. Requires knowledge of a variety of system applications both internal and external. Determines and initiates action to resolve rejected invoices, prepares payer corrections, and/or appeals using electronic and paper processes.
• Provide guidance, assistance, education, and communications with internal and external customers related to insurance and government payers claims processing protocols.
• Utilize various resources to determine patient’s eligibility, benefits, and health plan confirmation. Including online payer databases, CareCentrix Eligibility platforms, and medical records that may result in provider or payer recoup/rejection activity.
• Oversee accounts receivable adjustments to resolve overpayments and payment rejections according to standard operating procedures. Analyze and clears payment variances. May prepare adjusted and corrected bills or adjust accounts receivable entries in accordance with existing operating procedures. May include the use of special reporting.
• Evaluate, analyze and monitor the processing of invoices and on-line notes, utilizing a Windows based data processing system. Monitors payer responses, using Microsoft Excel, Microsoft Access and other software as necessary to ensure prompt payment.
• Contact providers, physicians, and/or patients to retrieve appropriate medical documentation to substantiate services provided and engage them in assisting CareCentrix in collecting for the payer.
• Provide payers with detailed itemization of services performed to ensure timely reimbursement.
• Review EOPs/EOMBs/EOBs for accuracy of patient responsibility.
• Provide input on accounts receivable process improvements and assisting in their implementation.
• May acts as an information resource for hard to collect accounts and a “grey area” subject expert.
• Ensure the coordination of special handling or reconciliation of spreadsheets for national payers.
• Works with internal customers to identify issues which may result in new enhancements or platforms as necessary.

Qualifications

You should reach out if you have:

• High School Diploma or the equivalent. 
• Two years medical claims processing and reimbursement experience generally required. Knowledge of healthcare collection procedures and related internal and external software applications are required.
• Effective analytical, verbal and communication skills also required as well as knowledge of HIPPA, The Fair Credit and Collections Act, HCPC, CPT, ICD-9 coding, intermediate competency of Microsoft Office Applications, and mathematical calculations.
• Knowledge of Utilization Management and URAC standards. Basic competency of Microsoft office applications and mathematical calculations is required.
• Must be well organized and possess excellent time management skills.

What we offer:

• Starting Pay for external hires is $18.00/ hour + Incentive Bonus Opportunity. The pay range included in this posting reflects future growth / earning potential.
• Full range of benefits including Health, Dental and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match
• Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training and more
• Advancement Opportunities, professional skills training, and tuition /exam reimbursement
• PayActiv - access earned income in between pay checks
• Walgreens Discount - receive up to 25% off eligible items
• Great culture with a sense of community

CareCentrix maintains a drug-free workplace

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We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.

CareCentrix accepts applications on an ongoing basis until a candidate is identified.