Claims Resolution Specialist Jobs (NOW HIRING)

PRIMARY PURPOSE

Responsible for investigating, analyzing, and resolving complex claims and payment disputes. This role ensures accurate claims adjudication by reviewing provider disputes, member grievances, and payment discrepancies. Collaborates with cross-functional teams to ensure compliance with federal and state regulations while driving process improvements to enhance operational efficiency.

MINIMUM SPECIFICATIONS

Education

• High School Diploma required.

• Bachelor's degree in business administration, accounting, finance or a related field is preferred.

Experience

• Six years of experience in claims processing or claims data resolution in a health care organization.

• Experience in Medicaid Claims Encounters for the State of Texas is preferred.

• Strong experience working with claim encounters and/or HIPAA X12 (EDI) transactions is preferred.

• Experience with QNXT or FACETS claims system is preferred.

• Experience in a Health Plan or Managed Care Organization (MCO) is preferred.

Equivalent Education and/or Experience

• None.

Certification/Registration/Licensure

• None.

Required Tests for Placement

• None.

Skills or Special Abilities

• Knowledge of HCFA 1500 and UB04 billing forms and related data interpretation.

• Strong working knowledge of health insurance concepts, practices and procedures including understanding of provider payment methodologies and claims processing workflows, from receipt through final adjudication.

• Strong analytical and research abilities to triage issues and perform reconciliations or data analysis.

• Working knowledge of Federal and State regulatory rules regarding claims adjudication.

• Ability to identify root cause for issues and incorporate findings into process improvement initiatives.

• Detail oriented and able to work issues to resolution.

• Excellent verbal and written communication skills to interact with internal and external stakeholders.

• Strong organizational skills and the ability to manage multiple competing projects and deadlines.

• Proficiency with Microsoft Office Excel, Word, and Outlook is required.

• Demonstrated ability to collaborate effectively and work as part of a team in a fast-changing environment.

• Strong knowledge of Texas State Medicaid Guides & Handbooks - TMHP Provider Manuals, Uniform Managed Care Contract (UMCC), Uniform Managed Care Manual (UMCM), etc. is preferred.

Responsibilities

• Manages the efforts of researching and resolving claims and claim encounter issues in a timely manner.

• Resolves issues related to claims and encounters through end-to-end review (data received, loaded, processed, reported, etc.). Identifies the cause of the issue and resolves through collaboration with all departments and individuals involved in the area of the identified concern.

• Understands the impact of PCHP's various departmental functions on claims adjudication and collaborates with other departments (e.g. Provider Relations, Network Management, Member Relations) to resolve issues impacting claim payments.

• Identifies trends related to claim issues and advises leadership on interdepartmental process improvement opportunities to resolve provider abrasion.

• Provides information requested and resolves problems that arise involving claims.

• Serves as PCHP's subject matter expert for claims and claim encounters.

• Collaborates with PCHP's vendor(s) to resolve issues preventing encounter data from being submitted to and/or accepted by HHSC.

• Monitors claims and encounters key performance metrics and escalates issues when warranted.

• Partners with PCHP departments and vendors on the implementation of new programs and products.

• Communicates, collaborates and cooperates with internal and external stakeholders in a respectful and responsible manner.

• Adheres to all compliance requirements and complies with HIPAA regulations.

• Performs other duties or special projects as assigned.

Job Accountabilities

• Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.

• Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.

• Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.