Researches and Resolves High Dollar Insurance Payer Underpayments through concise understanding of Payer Contract language and respective payment calculation. Position requires individuals with high mathematical acumen, ability to access and assimilate data, articulate a strong case, confidence, and strong persuasion skill set. Results oriented individual will be required to work through various options available to liquidate the most difficult high dollar underpayments. Candidate will demonstrate ability to grow strategic payer relationships and obtain understanding of payer system to navigate through claims processing centers. Critical thinking skills are necessary, as well as ability to see trends that require escalation to the Payment Compliance Director. Responsible for bundling similar cases not resolved through the standard Payment Compliance process and escalate to Dispute Resolution Team for legal action.
Duties (included but not limited to):
Analyzes hospital claims to identify contractual underpayments or billing errors.
Resolves underpaid claims from various payer products including HMO, PPO, Medicaid, Medicare and Workers' Compensation.
Articulates contract provisions to representatives from healthcare payer companies and government agencies.
Contacts payer companies via phone or correspondence and initiates request for payment.
Performs appropriate follow up with Payer and gains commitment for payment.
Escalates Payer lack of response and/or lack of payment within Payer organization as appropriate.
Identifies and communicates contract interpretation issues and language discrepancies to leadership as appropriate.
Identifies Payer company trends and communicates trends to supervisor for further action/escalation.
Serves as a subject matter expert in Payer contract dispute resolution process.
Practices and adheres to the "Code of Conduct" philosophy and "Mission and Value Statement"
Other duties as assigned
KNOWLEDGE, SKILLS & ABILITIES
Communication - communicates clearly and concisely, verbally and in writing.
Persistence comfortable pursuing, rebutting and escalating issues as appropriate.
Goal-oriented holds him/herself accountable to achieving shared and personal goals.
Customer orientation - establishes and maintains long-term customer relationships, building trust and
respect by consistently meeting and exceeding expectations.
Interpersonal skills - able to work effectively with other employees, patients and external parties.
PC skills - demonstrates high proficiency in Microsoft Office applications and others as required.
Policies & Procedures - demonstrates knowledge and understanding of organizational policies,
procedures and systems.
Mathematical skills - able to perform advanced mathematical calculations and balance and reconcile figures
Writing skills advanced writing skills with ability to present a compelling argument, punctuate properly, spell correctly and transcribe accurately.
Bachelor's degree required.
Master's degree preferred.