Job Summary

The Claims Resolution Specialist is the first line of contact for providers. The incumbent will assist providers with questions related to the payment of claims and resolution of claims payment issues.

Position Responsibilities

Claims Support

• Responds and researches issues on provider questions regarding claims payments, denials, resolves claim issues, contractual and/or agreements, established payment methodologies, division of financial responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures.

Follows up with providers as needed.

Administrative Support

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Ensures accurate and timely documentation regarding all issues, and/or inquiries are entered in Facets.
• Routes escalated calls to the appropriate departments and/or management.
• Other duties or projects as assigned.

Possesses the Ability To:

• Meet and maintain established quality and production standards.
• Work independently and as part of a team.
• Develop and maintain effective working relationships with all levels of staff and providers.
• Handle multiple tasks and meet deadlines.
• Communicate clearly and concisely both verbally and written.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.