Claims Resolution Specialist

At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our purpose is simple - we strive to bend the cost curve in healthcare for all. Our dedication to service excellence extends to all our stakeholders - internal and external - driving us to consistently exceed expectations. We are intentionally bold, we foster innovation, we nurture accountability, we champion diversity, and empower each other to illuminate our collective potential.

Be part of our amazing transformational journey as we optimize the opportunity towards becoming a leading technology, data, and innovation voice in healthcare. Onward and Upward!!!

JOB

ROLES AND RESPONSIBILITIES:

1. Manage a high volume of healthcare claims thoroughly to maximize savings opportunities on each claim within the established department production standards and individual goals by contacting provider on all assigned claims and presenting a proposal while maintaining high quality standards.

* Perform provider research to provide support for desired savings.

* Address counteroffers received and present proposal for resolution while adhering to client guidelines and policy and procedures.

* Seek opportunities to achieve savings with previously challenging/unsuccessful providers.

* Seek opportunities to establish ongoing global or concurrent agreements for future claims.

* Update provider data base for reference and claims processing on subsequent claims.

2. Initiate provider telephone calls as often required with respect to proposals, overcome objections and apply effective telephone negotiation skills to reach successful resolution on negotiated claims.

* Up to 40% of time will be on phone with providers.

* Provider education to providers online provider portal services available for proposal review and approval

3. Meet and maintain established departmental performance metrics.

4. Handle post claim closure service inquires, including payment status and defending original negotiation terms.

5. May require ACD phone responsibilities and tracking outcomes.

6. Collaborate, coordinate, and communicate across disciplines and departments.

7. Ensure compliance with HIPAA protocol.

8. Demonstrate Company's Core Competencies and values held within.

9. Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.

10. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned, as necessary.

JOB SCOPE:
The Individual adheres to company policies and customer specific procedures to meet control standards. The Individual relies on established instructions and procedures, applies basic skills, and may develop advanced skills using tools and equipment appropriate for the position. Duties and tasks are standardized and generally contain written instructions, allowing an individual to resolve routine questions and problems, and referring more complex issues to a higher level.

Work is subject to defined work output standards and production which involves high volume claims resolution. Work involves direct contact with internal and external customers.

JOB REQUIREMENTS (Education, Experience, and Training):

* Minimum high school diploma or GED

* Minimum 6 months experience in the health care industry (provider billing, medical coding, provider collections, insurance, or managed care); 1 year preferred.

* State licensure certification, including NY Health and/or P&C State Adjustor license, may be required. If hired without certification, certification must be obtained, and maintained thereafter, within six months of notification. If the required state licensure certification(s) are not obtained or renewed within six months of notification, an employee may be moved to a position within a relevant job family that does not require certification/licensure, if and when such position is available.

When an alternate position is unavailable, other employment actions may be implemented consistent with Multi Plan practice and policy.

* Knowledge of applicable laws and statutes (state, local or federal) for positions focusing on Workers' Compensation or automobile medical ("auto") bills a plus

* Knowledge of general office operations and/or experience with standard medical insurance claim forms

* Good Communication (verbal, written and listening) teamwork, negotiation, and organizational skills.

o Ability to process verbal and written instructions.

o Display professionalism by having a positive demeanor, proper telephone etiquette and use of proper language and tone in a business professional environment.

* Ability to:

o Commit to providing a level of customer service within established standards.

o Provide attention to detail to ensure accuracy including mathematical calculations.

o Identify issues and determine appropriate course of action for resolution.

o Organize workload to meet deadlines and participate in department/team meetings.

o…