Gainwell Technologies is an award-winning digital health technology company that supports the administration of healthcare and human services programs. In past
Provider Enrollment Analyst
Location
Nevada
Posted
1 day ago
Salary
0
Seniority
Senior
Job Description
Provider Enrollment Analyst
Gainwell Technologies
• Help create the power in Gainwell’s processes as we develop purpose-built technologies and solutions that yield better health and human services outcomes • Share your expertise as you support the Business Process Services team in claims processing that adheres to policy guidelines • Meet production and quality requirements established by clients for timely claims processing • Use policy guidelines and criteria established by leadership to evaluate why a claim errored and make an adjudication decision
Job Requirements
- Knowledge of the fundamental concepts and principles in the medical and/or insurance fields
- Basic reading and analysis skills to evaluate claims and make adjudication decisions
- Basic computer use skills
- Ability to multi-task across multiple claims to work efficiently
- Ability to work independently to meet individual production goals
Benefits
- Opportunities to travel through your work (0-10%)
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Role Description - Manage guest incident claims from intake through resolution, escalation, or litigation referral, ensuring timely investigation, documentation, evaluation, and follow-up. - Conduct claim review, investigation, and risk assessment to identify exposure, escalation triggers, documentation gaps, and appropriate next steps. - Collect, review, and analyze claim-related documentation, including incident reports, photographs, witness statements, receipts, communications, and other supporting materials. - Evaluate guest incident claims for completeness, liability indicators, potential litigation concerns, policy application, and allocation applicability. - Exercise sound judgment in determining when claims require escalation, additional investigation, management review, or litigation referral. - Serve as a primary operational liaison between Legal, Risk, Operations, Guest Relations, third-party administrators, insurance partners, and outside counsel. - Coordinate with third-party administrators on claim status, documentation needs, investigation follow-up, escalation, reserve or exposure concerns, and resolution strategy. - Review TPA claim updates, assessments, and recommendations, and identify issues requiring additional action, escalation, or Sr. Manager review. - Attend claim reviews with third-party administrators and support follow-up on action items, trends, and open issues. - Monitor claim activity and proactively identify inconsistencies, missing information, recurring issues, or operational gaps that may impact claim handling. - Review allocation disputes and provide recommendations based on Company policy, available documentation, supporting evidence, and established guidelines. - Support oversight of claim handling expectations, escalation protocols, reporting requirements, and TPA performance. - Maintain and update guest incident handling procedures, allocation guidelines, chargeback processes, claims administration materials, and related policies in partnership with the Sr. Manager. - Identify trends in guest incidents, claim activity, recurring issues, or policy gaps and recommend operational or process improvements to reduce exposure and support risk mitigation. - Assist in developing and implementing best practices related to claims handling, investigation standards, documentation requirements, escalation protocols, allocation management, and claim file maintenance. - Support training, guidance, and communication efforts related to guest incident documentation, claim handling procedures, and claims administration processes. - Other tasks as assigned by manager. - Provide litigation support for escalated guest incident claims and related matters, including document preservation, file organization, case tracking, and coordination with internal partners and outside counsel. - Ensure claim and litigation files are complete, accurate, organized, and maintained in claim and matter management systems. - Coordinate with outside counsel and internal stakeholders regarding document collection, case updates, deadlines, and litigation support needs. - Monitor litigation deadlines, milestones, follow-up items, and matter activity to support case management and litigation strategy. - Maintain accurate matter management system updates, litigation records, claim notes, reporting fields, and supporting documentation. - Process and review outside counsel and vendor invoices for accuracy, completeness, compliance, and appropriate coding. - Support litigation reporting, claims metrics, audits, trend analysis, and other operational reporting for the Legal team. - Identify and recommend efficiencies in claims administration, litigation workflows, documentation practices, reporting processes, and matter management procedures. - Provide guidance and informal mentoring to less experienced team members as appropriate. Qualifications - 6+ years of experience in claims management, risk management, investigations, litigation support, insurance administration, legal operations, or a related environment. - Strong understanding of claims handling practices, liability evaluation, risk assessment principles, litigation readiness, and claim documentation standards. - Demonstrated ability to independently manage claims, competing priorities, sensitive matters, and complex workstreams with limited supervision. - Experience working with third-party administrators, outside counsel, insurance partners, claims management systems, matter management systems, and cross-functional business stakeholders. - Ability to interpret and apply policies, procedures, allocation guidelines, escalation protocols, and supporting documentation. - Strong investigative, analytical, organizational, and problem-solving skills. - Sound judgment and decision-making skills, particularly in sensitive, high-risk, or time-sensitive situations. - Strong written and verbal communication skills, with the ability to communicate clearly and professionally with internal and external stakeholders. - Ability to handle confidential and sensitive information with discretion and professionalism. - Proficiency in Microsoft Office applications, including Outlook, Word, and Excel; experience with claims or matter management systems preferred. Requirements - Compensation Range: $67,000.00 - $92,125.00 Company Description - Red Robin is an Equal Opportunity & E-Verify Employer.
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