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Claims Resolution Specialist - Albuquerque New Mexico at Magellan Health Services inc in Albuquerque, New Mexico

Posted in General Business 30+ days ago.

Type: Full-Time

Job Description:

Candidates must be located in \tAlbuquerque, New Mexico

This position is responsible for accurate and timely research of all claim dispute types, timely processing of adjustments and acts as liaison between members, providers and internal claims departments. If a recalculation is warranted and modification to the payment amount is determined to be required, acting within established parameters, this role makes the appropriate payment adjustment into the claims system. Must complete duties with a high level of detailed quality and professionalism.

  • Assists with claim dispute resolution through research and facilitating the resolution of the problem within contractual timeframes.

  • Acts as a troubleshooter to resolve claim processing problems among internal departments, including authorization issues.

  • Completes data entry for tracking and reporting of claim disputes.

  • Adjudicates claims and adjustments.

  • Assists in providing daily guidance for associates to obtain optimal results.

  • Ensures documentation is entered into the appropriate system to ensure all pertinent information is recorded both for ease of resolution by the Claims Department and service continuation for the customer.

  • Processes adjustments to include tracking and trending performance of root cause analysis.

  • Updates members and providers with the disposition of payment as appropriate.

  • Identifies system/benefit errors completing protocols and workflows to prevent future errors.

  • Handles all types of requests, inquiries and complaints accurately and timely.

  • Provides re-enforcement training for new and existing associates as needed.

  • Responds to written correspondence and phone inquiries from internal customers.

  • Assists with handling internal routes (i.e. rates, provider membership issues).

  • Seeks, gathers and analyzes relevant data to address problems effectively.

  • During peak call volumes, may provide back-up phone coverage from members and providers with inquiries related to eligibility, benefits, claims, authorization of services and/or other Magellan products and services.

Other Job Requirements


  • Ability to review and interpret contract/account information to successfully resolve issues regarding claim disputes.

  • Demonstrated ability for problem solving, meeting deadlines, showing initiative and follow-through.

  • Must be a proficient typist.

  • Working knowledge of Microsoft Office Product Suite, specifically Excel.

  • Ability to simultaneously maneuver through various computer claims and eligibility platforms while verifying information while on the telephone.

  • Excellent verbal and written communication skills.

  • Must demonstrate professional call handling skills while under stress.

  • Customer service oriented and a team player.

  • Must maintain member and provider confidentiality at all times.

  • Must be flexible in scheduling, be punctual and maintain good attendance.

  • Understanding of customer service performance metrics (ASA, abandonment rate, talk time).

  • Comfortable adapting to change.

Bilingual preferred.

General Job Information

Work Experience
Bilingual, Claims, Customer Service

GED (Required), High School (Required)

License and Certifications - Required

License and Certifications - Preferred

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.