Posted in Other 30+ days ago.
Type: Full Time
JOB SUMMARY: This position is responsible for the handling, research, and communication regarding complex and escalated claims inquiries stemming from patients, clients, providers, and internal customers', including both intake and resolution. In addition, this position is also responsible for coaching and mentoring.
JOB ROLES AND RESPONSIBILITIES:
1. Investigate, analyze, research, and resolve complex and escalated claim inquiries from patients, clients, providers, and internal customers' as a result of issues related to discounts, payments and balance billing. This includes handling legal inquiries or department of insurance complaints.
2. Provide resolution and closure to the applicable recipients. Create and execute business correspondence to clients or providers using multiple media formats such as but not limited to emails, form letters, and issues specific letters. This includes initiating resolution and follow up calls to clients and providers.
3. Adhere to client turn around requirements as it relates to response time and required actions.
4. Ensure investigative notes related to any contact with providers and clients are documented and accessible throughout the applicable systems.
5. Ensure the maintenance of and compliance with department standards for production, accuracy, and turnaround time.
6. Perform system claim adjustments based on outcomes and communicate with client regarding confirmation.
7. Assume and resolve escalated claim and inquiries from team members. Serves as back-up for team members, or Leadership.
8. Coach and mentor less experienced team members on claims handling, resource utilization, and appropriate resolutions.
9. Assist in training new team members as needed and providing feedback to Leadership.
10. Various research projects for Sr. Management and Clients, as assigned.
11. Collaborate, coordinate, and communicate across disciplines and departments.
12. Ensure compliance with HIPAA regulations and requirements.
13. Demonstrate Company's Core Competencies and values held within.
14. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.
Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.
JOB SCOPE:
The incumbent works under minimal supervision to complete job responsibilities in applying a fundamental knowledge of principles, practices and procedures related to the servicing of inquiries and providing resolution and follow-up, where necessary. Work is complex and requires independent judgment within established guidelines; however, may seek guidance from management as needed. This job has regular contact with external and internal customers. Individual may act as a primary contact for priority clients. While this is not a supervisory job, an incumbent acts as a resource to the Team and may provide input to management on training recommendations.
JOB REQUIREMENTS (Education, Experience, and Training):
* Minimum completion of high school (i.e., diploma or GED)
* Minimum 3 years experience in the healthcare industry or customer service, preferably with out-of-network claims.
* Required licensures, professional certifications, and/or Board certifications as applicable.
* Bilingual English/Spanish may be required of some positions.
* Knowledge of health care claims and appeal procedures .
* Knowledge of insurance company and medical service provider vocabulary desirable
* Communication (written, verbal and listening) problem solving, interpersonal and decision-making skills.
* Ability to create and compose business correspondence
* Ability to multitask while setting priorities
* Ability to analyze data and arrive at a logical conclusion
* Ability to identify issues and determine appropriate course of action for resolution
* Ability to elicit trust and credibility with all levels of the organization
* Ability to work with accuracy in a fast-paced environment
* Ability to adjust/alter workflow to meet deadlines
* Ability to work independently as well as part of a team
* Ability to handle confidential information.
* Ability to handle high pressure situations and variance in workload volume
* Ability to use software, hardware and peripherals related to job responsibilities including MS Office
* Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone
As an Equal Opportunity Employer, the Company will provide equal consideration to all employees and job candidates without regard to sex, age, race, marital status, sexual orientation, religion, national origin, citizenship status, physical or mental disability, political affiliation, service in the Armed Forces of the United States, or any other characteristic protected by federal, state, or local law..
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Kroger |
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Kroger Manufacturing |
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Kroger Manufacturing |