Claims Resolution Representative

Company Overview:

Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Job Summary and Responsibilities:

Acentra Health is looking for a Claims Resolution Representative to join our growing team.

Job Summary:

The Claims Resolution Representative plays a vital role in ensuring accuracy and adherence to the applicable state's Department of Health guidelines. This position serves as a crucial liaison between members, providers, agencies, and the internal claims department, demonstrating leadership, collaborative skills, and commitment to achieving results.

Responsibilities:

• Independently resolve suspended claims using the resolution screens in accordance with operational procedures and process recoupments.
• Determine when to use a "Forcible" disposition to override the edit and process the claim based on operational claims adjudication procedure.
• Review and analyze claims and follow up on the status of claims and reimbursement.
• Interpret and apply policy and reimbursement rules to support provider inquiries.
• Ensure accuracy and consistency in claims processing.
• Research and review submitted claims (paper or electronic) and process them according to Wyoming Department of Health policies and procedures.
• Possess an unwavering commitment to customer service and operational excellence.
• Perform manual pricing and audit checks to ensure compliance with Wyoming policies and rules.
• Review and process suspended claims and submitted documentation.
• Provide sufficient detail to explain claims denial reasons.
• Implement workflow processes and capabilities for work queues with the ability to route workstreams between Acentra and the state.
• Approve or deny requests for transportation authorization from providers, verify member transportation claims, and process approved claims.
• Perform manual reviews on claims, documents, and attachments.
• Release individual claims for providers on review.
• Independently resubmit claims with applicable corrections.
• Independently address discrepancies in charges, payments, adjustments, and demographic information.
• Facilitate manual entry of claims into the system.
• Review paper claims and attachments, scanning them using scanning equipment to attach the documents to corresponding transaction control numbers.
• May make outbound calls as related to workload.
• Other duties as assigned.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

Qualifications:

Required Qualifications

• High School Diploma or GED
• Be available to work from 8:00 AM to 5:00 PM Mountain Time on all State business days, Monday through Friday (excluding State holidays)

Preferred Qualifications

• Ability to maneuver through various computer claims and eligibility platforms simultaneously
• Outstanding customer satisfaction skills
• Must be firm but professional when interacting with contacts while performing tasks
• Friendly personality, tact, patience, empathy, and a helpful yet professional attitude are essential
• Strong computer skills, including proficiency in MS Word and Excel
• Excellent oral and written communication skills
• Excellent organization and time management skills, with the ability to establish priorities effectively
• Ability to read, write, and follow directions
• Ability to collaborate effectively with others
• Demonstrate leadership through consistent on-site (or offsite for remote) attendance
• Knowledgeable in claims review and analysis
• Familiarity with Medicare and Medicaid

Why us?

We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.

We do this through our people.

You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.

Benefits

Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.

Thank You!

We know your time is valuable and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may be of interest. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team

EEO AA M/F/Vet/Disability

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

Compensation

The pay range for this position is listed below.

“Based on our compensation philosophy, an applicant’s position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.”

#LI-AF1

Pay Range: USD $18.62 - USD $21.00 /Hr.