What are important things that YOU need to know about this role?
This position is full-time, permanent remote
Hours: flexible. Monday through Friday day hours CST
Organization, attention to detail and accuracy are keys to success in this role
What will YOU be doing for us? Ensure accurate and timely payment of claims to providers. Utilize research and knowledge of coverage and benefits to ensure resolution to more difficult claim payment issues.
What will YOU be working on every day?
Submit accurate and timely payments to providers, keeping within contractual service level agreements for each market. Develop and maintain controls over the proprietary processed data and systems set up through developing and implementing auditing procedures, and identifying potential claim audit exposures.
Interpret and understand coverage and benefit limitations by having a comprehensive understanding of benefits and state requirements for multiple markets.
Assure that claims are paid within the expected time frames by monitoring inventory control and working with team members and appropriate resources in other areas to resolve issues related to claims entry.
Identify trends and suggest and develop efficiencies in the review of edit reports and other documentation by reviewing procedures and making appropriate suggestions and adjustments to procedures.
Resolve complex claim payment inquiries by analyzing patient activity and related documentation (including enrollment, claims, and authorizations) and determine appropriate action to be taken.
Resolve complex client issues that may require research, analysis and working with management.
Complete requests for claims review and/or reprocess within internal guideline turnaround times.
Additional Responsibilities:
Develop and maintain client and provider relationships by interacting directly with the client and providing necessary feedback and communications as needed.
Provide training and guidance to team members on market specific issues by providing feedback to management on claims and provider issues, and updating client business rules and check run procedures as needed.
Partner with Reimbursements team in completing all other tasks as necessary to ensure accurate and timely check runs and internal turnaround times.
PHO only- Post received checks to the appropriate claims. Reconciling posted amount to amount received
PHO only- Prepare and submit billing date to insurance companies
PHO only – Participate in monthly meetings with client
What qualifications do YOU need to have to be GOOD candidate?
Required Level of Education, Licenses, and/or Certificates
High school diploma or equivalent
Required Level of Experience
2 years of prior job related experience (Dental Assistant, Dental/Medical Office Manager, Dental/Medical front office, or health/dental insurance, including managed care operations, accounts receivable and or billing)
Required Knowledge, Skills, and Abilities
Knowledge of health or dental procedures coding and terminology.
Basic knowledge of Microsoft software (Outlook, Excel and Word).
Exceptional written and verbal communication skills.
Competencies
Fostering Innovation: The ability to develop, sponsor, or support the introduction of new and improved method, products, procedures, or technologies.
Critical Thinking: The ability to analyze/evaluate information as presented, utilize past experience to make decisions that are logical and reasonable and demonstrate sound judgment.
Initiative: Identifying what needs to be done and doing it before being asked or before the situation requires it.
Results Orientation: The ability to focus on the desired result of one’s own or one’s unit’s work, setting challenging goals, focusing effort on the goals, and meeting or exceeding them.
Detail Oriented: Ensuring that one’s own and/or others’ work and information are complete, timely and accurate; carefully preparing for meetings and presentations; following up with others to ensure that agreements and commitments have been fulfilled.
Time Management: The ability to manage several competing tasks at once effectively while still meeting deadlines.
What qualifications do YOU need to have to be GREAT candidate?
Preferred Level of Education, License, and/or Certificates
Bachelor’s Degree in a related field
Preferred Level of Experience
Knowledge of vision claim processing
Preferred Knowledge, Skills, and Abilities
None
PHO Only: Knowledge of Enterprise Systems
Medical Claims
EDI Claim Submission
The salary range and midpoint is listed below for your reference. Please keep in mind that your education and experience along with your knowledge, skills and abilities are taken into consideration when determining placement within the range.
Compensation Range:
$39,115.00 – $58,672.00
Compensation Midpoint:
$48,894.00