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Years of Experience
Date Last Verified
ProfileAssociate Claims and Resolution Analyst The candidate will provide assistance in claim resolution for higher complexity claims and those in litigation. Will provide negotiation services to achieve higher client discounts on claims. Represent organization and be customer facing. Work for a place where management encourages responsibility, communications and problem solving. Have an overall impact on containing healthcare costs while doing rewarding work. Claims. Resolution/Negotiation. Determine the optimal claims resolution strategy based on Client, Facility and identified hospital bill review exceptions. Modify claims resolution strategies and legal arguments as warranted to ensure successful closure. Recommend and ensure that the Client is in agreement with the proposed claims resolution strategy, including—but not limited to—acceptance of all identified hospital bill review exceptions, out-of-network discount, additional in-network discount, negotiation and settlement, or expiration of provider appeals timeline. Work with the Clinical, Account Management and/or Legal Teams as required to uphold hospital bill review exceptions through the claims settlement or provider appeals process. Lead the claims resolution effort for assigned claims, including all verbal and written communication with Facilities, Clients and other third parties. Understand and maintain HIPAA confidentiality and privacy standards when completing assigned work. Contribute to development of business rules, regulations and process improvements. Contribute to development of/enhancements to internal systems (ex. Information technology system).
Qualification and Experience
The candidate should have 5+ years of progressive business experience preferably in a managed care environment. Bachelor’s Degree; emphasis in nursing, accounting, finance, law or business administration is preferred. Provider relations, negotiation and contracting experience, large claims resolution or other negotiation experience is required. Good computer skills, including to—Word and Excel is essential.