Role Description The claims resolution representative plays a vital role in ensuring accuracy and adherence to the applicable 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. - This position is remote within the United States, but applicants can expect to work Eastern Time regular business hours with some flexibility. 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 (electronic) and process them according to policies and procedures. - Possess an unwavering commitment to customer service and operational excellence. - Perform manual pricing and audit checks to ensure compliance with 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 workstreams. - 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. - Other duties as assigned. - Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules. Qualifications - High School Diploma or GED - 1+ years of experience conducting research to resolve issues within the healthcare field Requirements - 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 - Self-directed and capable of working without direct supervision - Ability to collaborate effectively with others - Create and maintain a positive atmosphere, demonstrating leadership qualities - Knowledgeable in claims review and analysis