If you know how to break down a claim, spot what doesn’t add up, and confidently negotiate with providers, this role puts that skill to work every day. You’ll negotiate out-of-network payments for group health plans using cost data (reasonable and customary, Medicare pricing) and by identifying billing irregularities.
About Allied Benefit Systems
Allied Benefit Systems supports employer health plans with claims administration and related services. Their teams work to ensure claims are reviewed accurately, negotiated appropriately, and handled in compliance with privacy and security standards.
Schedule
Remote
Full time
What You’ll Do
- Negotiate out-of-network claim payments with providers and secure discounts
- Review and analyze claims for cost reasonableness, medical necessity concerns, and potential fraud indicators
- Determine benefit eligibility and payment levels based on each client’s customized plan terms
- Reprice claims to applicable Medicare rates when required
- Request and review supporting documentation (physician notes, hospital records, police reports) as needed
- Identify billing irregularities by reviewing CPT/diagnosis codes and claim details
- Analyze claims for billing inconsistencies and document findings in required systems
- Process claims and add notes within the QicLink system and other internal platforms
- Log negotiated claims in an Access database and produce weekly summary reports
- Review Suspended Claim Reports and follow up on unresolved issues
- Collaborate with internal partners and outside entities when additional evaluation is needed
- Maintain compliance with HIPAA and other applicable privacy/security requirements
- Attend required continuing education, including HIPAA training
- Support team needs and complete other duties as assigned
What You Need
- Bachelor’s degree or equivalent work experience
- 5+ years of medical claims analysis experience
- Strong analytical skills and attention to detail
- Knowledge of CPT and ICD-9 coding terminology
- Comfort working across multiple systems and documenting work consistently
Benefits
Allied offers a total rewards package that may include medical, dental, vision, life and disability insurance, generous paid time off, tuition reimbursement, EAP, and a technology stipend (eligibility and details provided during the hiring process).
This one is built for someone who can think like an investigator and negotiate like a professional.
Happy Hunting,
~Two Chicks…