Claims Resolution Representative

Company Overview

Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem‑solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra Health is looking for a Claims Resolution Representative to join our growing team.

Job Summary: The Claims Resolution Representative plays a vital role in ensuring accuracy and adherence to the applicable state's Department of Health 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.

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 (paper or electronic) and process them according to Wyoming Department of Health policies and procedures.
• Possess an unwavering commitment to customer service and operational excellence.
• Perform manual pricing and audit checks to ensure compliance with Wyoming 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 work streams between Acentra and the state.
• 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.
• May make outbound calls as related to workload.
• 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
• Be available to work from 8:00 AM to 5:00 PM Mountain Time on all State business days, Monday through Friday (excluding State holidays)

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
• Ability to collaborate effectively with others
• Demonstrate leadership through consistent on-site (or offsite for remote) attendance
• Knowledgeable in claims review and analysis
• Familiarity with Medicare and Medicaid

We are a team of experienced and caring leaders, clinicians, pioneering…