Claims resolution specialist job description

Job DescriptionThis position is responsible for accurate and timely research of all claim dispute types, timely processing of adjustments and acts as liaison between members, providers and internal claims departments. If a recalculation is warranted and modification to the payment amount is determined to be required, acting within established parameters, this role makes the appropriate payment adjustment into the claims system. Must complete duties with a high level of detailed quality and professionalism.

Assists with claim dispute resolution through research and facilitating the resolution of the problem within contractual timeframes.

Acts as a troubleshooter to resolve claim processing problems among internal departments, including authorization issues.
Completes data entry for tracking and reporting of claim disputes. Adjudicates claims and adjustments. Assists in providing daily guidance for associates to obtain optimal results. Ensures documentation is entered into the appropriate system to ensure all pertinent information is recorded both for ease of resolution by the Claims Department and service continuation for the customer. Processes adjustments to include tracking and trending performance of root cause analysis. Updates members and providers with the disposition of payment as appropriate. Identifies system/benefit errors completing protocols and workflows to prevent future errors. Handles all types of requests, inquiries and complaints accurately and timely. Provides re-enforcement training for new and existing associates as needed. Responds to written correspondence and phone inquiries from internal customers. Assists with handling internal routes (i.e. rates, provider membership issues). Seeks, gathers and analyzes relevant data to address problems effectively. During peak call volumes, may provide back-up phone coverage from members and providers with inquiries related to eligibility, benefits, claims, authorization of services and/or other Magellan products and services.
Other Job Requirements
Responsibilities
Ability to review and interpret contract/account information to successfully resolve issues regarding claim disputes.
Demonstrated ability for problem solving, meeting deadlines, showing initiative and follow-through.
Must be a proficient typist.
Working knowledge of Microsoft Office Product Suite, specifically Excel.
Ability to simultaneously maneuver through various computer claims and eligibility platforms while verifying information while on the telephone.
Excellent verbal and written communication skills.
Must demonstrate professional call handling skills while under stress.
Customer service oriented and a team player.
Must maintain member and provider confidentiality at all times.
Must be flexible in scheduling, be punctual and maintain good attendance.
Understanding of customer service performance metrics (ASA, abandonment rate, talk time).
Comfortable adapting to change.
General Job Information
Title
Claims Resolution Specialist
Grade
18
Work Experience - Required
Claims, Customer Service
Work Experience - Preferred
Bilingual
Education - Required
Education - Preferred
Bachelors
License and Certifications - Required
License and Certifications - Preferred
Salary Range
Salary Minimum:
$34,295
Salary Maximum:
$51,445
This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.
This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

As a member of our Claims management team supervise claims staff to ensure appropriate claim outcomes through consistent execution of best claims practice. In this role utilize your prior claims and management experience to achieve business plan goals and to ensure compliance with legal statutes, policy provisions and company guidelines while fostering a culture of communication.
Responsibilities:

* Manages the assignment of losses to claims staff and provides technical direction and ongoing guidance through effective diary management.
* Ensures timely, accurate documentation of claim activity.
* Selects, trains, coaches and mentors unit personnel.
* Plans staff responsibilities and directs activities, utilizing staff resources effectively to meet department goals in accordance with approved plans and budgets.
* Develops staff to respond to current and anticipated needs of department as well as determining career development goals of individuals.
* Ensures appropriate case reserves consistent with company guidelines.
* Extends settlement authority on claims exceeding adjuster's granted authority.
* Develops, recommends and implements short range objectives consistent with company business goals, guidelines and programs.
* Recognizes and analyzes trends across the claims portfolio at the adjuster, unit and account levels.
* Reports on observations and recommends remedial action as needed.
* Administers salary and personnel programs under guidance of manager.
* Utilizes quality assurance programs and develops training agenda based on opportunities for improvement.
* Utilizes performance management process effectively, on an ongoing basis, to maximize performance of employees, correct performance problems, provide development opportunities, and promote effective communication with employees.
* Manages the account management process and resolves service issues.
* Promotes effective communication among and between work groups, and between management and employees.
* Demonstrate commitment to Company's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.
* Bachelor's degree and/or a minimum of three years of work experience in an insurance related industry required.
* Extensive knowledge of WC regulations (jurisdiction-specific), insurance contracts, applicable law and adjusting techniques.
* Previous supervisory experience.
* Familiarity with medical terminology.
* Demonstrated leadership, coaching, mentoring and teamwork skills
* Advanced skills in applying sound judgment/analysis, decision making/problem solving, planning and organization and negotiation.
* Excellent verbal and written communication skills.
* Excellent customer service and collaboration skills gained through previous work experience.
* Computer literacy, including working knowledge of MS Office Product Suite, i.e. Word, Excel, PowerPoint.
* Chartered Property Casualty Insurance (CPCU); Associate in Claims (AIC) designation or similar professional designation desired.
* Ability to travel for business purposes; approximately 15%

Job Code:
#551672

Title:
Claims Resolution Specialist

Job Type:
Direct Hire

Job Location:
Camp Hill PA


Job Description:

Claims Resolution Specialist
Join a growing healthcare company based in Pennsylvania. It owns long term acute care and inpatient rehabilitation hospitals, as well as occupational health and physical therapy clinics. 2 week training program provided for all applicants!

Pay: $16-17/hr

Hours: 8am-4:30pm

Location: Camp Hill, PA 17011

Duties:
- Working closely with insurance carriers
- Medicare billing

Required:
1) Eagerness to learn and work
2) Basic computer skills
3) Detail oriented and can multitask

Addison Group is an Equal Opportunity Employer. Addison Group provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. Addison Group complies with applicable state and local laws governing non-discrimination in employment in every location in which the company has facilities. Reasonable accommodation is available for qualified individuals with disabilities, upon request.

#talent HC
#zr4

Company DescriptionThe Addison Group is a leading staffing firm based in Chicago, IL that specializes in connecting opportunities and candidates in Administration & HR, Engineering, Finance & Accounting, Financial Services, Healthcare, and Information Technology. Founded in 1999, Addison Group has now established a coast to coast presence, with 22 offices nationwide: Austin, Boston, Charlotte, Chicago (HQ), Cupertino, Dallas, Denver, Houston, Minneapolis, Nashville, New York, Oklahoma City, Philadelphia, Phoenix, Reston, Rockville, San Antonio, San Francisco, Schaumburg, Seattle, Tulsa, and Washington, DC.

Named a “Top 50” Fastest Growing Company, Addison Group continues to achieve success and growth while fostering a competitive yet team-oriented environment. Addison Group is an Inavero’s Best of Staffing winner for the past six years. Addison Group is focused on organic growth—each year we promote people from within to open new branches and lines of business. Addison Group is a team-oriented work environment with a work hard/play hard atmosphere—Addison has been recognized by many publications as one of the top best places to work for the past five years. Visit our website to learn more: addisongroup.com