Senior Claims Research amp Resolution Professional

Profile

Description

The Senior Claims Research & Resolution Professional manages claims operations that involve customer contact, investigation, and settlement of claims for and against the organization. Approves all claim settlements both for and against the organization. The Senior Claims Research & Resolution Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Claims Research & Resolution Professional works with operational teams, vendors, providers, and members in the processing of claims. Serves as a content model expert and mentor to teams regarding policies, procedures, and regulatory requirements. Strong analytical skills focusing on accuracy and attention to detail. Product knowledge and experience with claims review processes, clinical terminology, and regulatory requirements will be needed. Advises executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks. Works under minimal supervision. Uses independent judgment requiring analysis of variable factors and determining the best course of action.

Required Qualifications


Bachelor's degree
5 or more years of technical experience
Coding certification (Industry-recognized coding certification from AAPC. Apprentice status will not be considered.)
Extensive knowledge of medical claims processing and are familiar with ICD, CPT, HCPCS, revenue and DRG assignment
Demonstrated ability to get things done in a rapidly changing environment
Demonstrated ability to influence decision making in different contexts
Excellent verbal and written communication skills and ability to adapt your communication style for the audience
Basic proficiency with MS Office (Excel, Word, and Access)
Possess self-drive and strong initiative, able to work with minimal supervision/direction


Preferred Qualifications


Experience with Medicare claim inquiries
Experience in managed care or health care administration
Experience managing vendor engagements


Additional Information

Scheduled Weekly Hours

40

Company info

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