Managed Care Claims Resolution Specialist - 134345

Candidates hired into this position may have the ability to work remotely, after training.

Under direction of the Provider Network Management/Contracts Manager, incumbent serves as the primary contact for incoming provider, health plan, and internal and external department calls, including documentation and follow-up via Epic CRM, as required for claims delegation compliance. Responsible for requesting, tracking and trending overpayment recoveries and adjustments for voided checks and refunds. Interprets and utilizes contract and benefit information to accurately process managed care claims for all lines of business, including COB adjudication. Responsible for Provider Dispute Resolution acknowledgements, ensuring responses are within CMS & DMHC guidelines. Investigates and presents complex cases to management for resolution. Interfaces with other departments to resolve eligibility, referral and Network Management related claim issues. Responsible for claim adjustments on previously processed claims related to a member out of pocket share cost. Prepares cost share worksheets to the health plans as requested. Other duties as assigned.

• Three (3) years relevant experience in a healthcare environment. One (1) year claims data entry and/or processing experience.

• Knowledge of current HMO claim adjudication protocols and guidelines and health plan delegation requirements.

• Working knowledge of CPT, ICD, ASA, and HCPCS coding as it pertains to claims administration.

• Proficiency with MS Office: Excel, Word, Outlook, etc.

• Excellent communication skills, both verbal and written.

• Epic Tapestry system experience.

• Managed Care experience.

• Epic Claims experience.

• Must be able to work various hours and locations based on business needs.

• Employment is subject to a criminal background check and pre-employment physical.