Claims Resolution Manager Jobs in Washington, DC

The Dental Claims Resolution Specialist will be responsible for investigating, recovering and resolving all types of claims.  Educate and inform members and providers of program coverage and limitations for claims within contract requirements.  Use critical thinking, research and problem-solving skills to navigate through the complexities of a member's health benefits and their respective claims while remaining within the program guidelines. 
 
Salary: $17.75 an hour plus $5.36 Health and Welfare.
 
Primary Responsibilities:
•    Maintain an ongoing responsibility for assigned claims inquiries which entails assessment, education and coordination for members/health care providers while keeping a detailed record within the internal database
•    Establish and maintain positive relationships with members, providers and our claims contractor
•    Demonstrates great depth of knowledge/skills in own function
•    Request and manage medical records to help determine potential program coverage and communicate results to the members
•    Completion of system generated tasks, including documenting all results as required
•    Prepare comprehensive reviews and summaries for claim appeals
•    Point of contact for internal departments to answer questions relative to member claims
•    Work with internal department to request code additions or other avenues to resolve issues in the program where appropriate
•    Understand the claim lifecycle and ensure that claims are resolved through the entire process
•    Solves moderately complex problems on own
•    Proactively identifies solutions to non-standard requests/inquiries
•    Work with the leadership team to resolve complex issues as needed
•    Able to handle emotionally charged phone calls and ability to deliver unfavorable claim outcomes
•    Ability to communicate complex program criteria into easily understood summaries in both oral and written communication
•    Validation of claim coverage in relation to program guidelines
•    Plans, prioritizes, organizes and completes work to meet established objectives and metrics
•    Complete activities and reporting as required by the fraud, waste and abuse plan
•    Monitor progress of Accounts Receivable targets and plans within contract KPI’s  (reword to remove A/R)?
•    Performs periodic and month-end balancing and reporting activities
•    Perform research/verification of identified claims to identify payment/overpayment issues/accuracy
•    Work with payers/providers to review claim information and identify issues related to payment accuracy
•    Document and communicate outcomes of claims investigations/overpayment reviews to applicable stakeholders
 

Requirements
•    Minimum of three years of claims processing or similar experience
•    Equivalent combination of education, experience and/or applicable military experience will be considered.
•    Proficient computer skills with Microsoft Office Suite experience
•    Ability to work independently as well as on a team
•    Excellent verbal and written communication skills including strong telephone etiquette and interpersonal skills with individuals at all levels of an organization
•    Demonstrated ability to adapt to performing a variety of duties, changing from one task to another of a different nature, without a loss of efficiency or composure
•    Must be able to implement critical thinking and decision making skills in order to identify appropriate care/treatment plans for a wide range of members from low to high complexity
•    Must have the ability to take initiative and be detail-orientated in a goal-orientated environment.
 
Preferred Qualifications:
•    Associate’s Degree in Business Administration or related field
•    Medical Coding, Registered Health Information Technician (RHIT) or equivalent
•    Medical call center experience or medical related experience in a corporate/business setting
•    Certified Medical Reimbursement Specialist CMRS exam completion
•    National Career Readiness Certificate
•    Dental claims processing experience
 

Sierra7 is a Small Disabled Veteran Owned Business. We were founded in 2009 with the mission of "Serving those who Serve". At Sierra7, we are focused on building a team of diverse leaders who are dedicated to our Mission and Values and motivated to advance our client’s mission. We are committed to creating a positive workplace environment that empowers our team members to find meaning in their work. Discover how a career at Sierra7 can help you achieve your potential.