The Group Health Claims Resolution Specialist works directly with group health payers and Central Billing Offices (CBO) to ensure accurate set-up with our billing systems and payer billing systems, identification and resolution of claim/billing issues.
Ensures the delivery of exceptional customer service by putting all customers (internal and external) first and displaying:
- A healing focus
- A selfless heart
- A tireless resolve
MAJOR DUTIES AND RESPONSIBILITIES:
***DIRECT PAYOR EXPERIENCE REQUIRED***
- Analyze cumulative claim reports to identify all large volume payment issues
- Obtains payer specific billing requirements, claims filing and appeal processes
- Monitor and report financial impact of newly implemented policies/processes
- Coordinate and facilitate action plan with payers when problems are identified
- Works with Central Billing Offices to implement set up of payer specific requirements and processes and correct/resolve billing and claims issues
- Research and notify involved departments regarding negative financial impacts relating to specific payers
- Works with group health credentialing department, group health payers, charge entry and Central Billing Offices to ensure proper linkage of providers to facilities and supervising clinicians
- Analyze payer reports for payment trends to ensure contractual obligations are being met
- Report, document and maintain claims processing changes to ensure up to date claims filing requirements
- Bachelors degree in a related field required
- If no degree, 4-6 years additional related/direct experience
- 5 – 7 years experience with group health payers regarding claims resolution and set-up requirements
- Working knowledge of claims, billing, coding, credentialing and contracting.
- Working knowledge of computer software applications including word and excel.
- Working knowledge/use of billing systems.
- Excellent oral and written communication skills.
- Excellent relationship building skills, attention to detail, deductive reasoning and decision making skills.
- Excellent instructional and teaching skills.
- Ability to manage and monitor multiple tasks and projects.
- Office environment
- 401(k) with Employer Match
- Medical/Vision/Prescription/Dental Plans
- Life Insurance/Disability
- Paid Time Off/Holidays
- Colleague Referral Bonus Program
This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.
Concentra is an Equal Opportunity Employer, M/F/Disability/Veteran.