Back to jobs
Job Description
- Claims Resolution & Support
- Serve as the primary liaison for complex escalated claim inquiries from providers, members, account management, and internal departments.
- Research and resolve complex claim discrepancies, denials, adjustments, and payment issues within established service-level agreements (SLAs).
- Coordinate with claims examiners, configuration, and payment integrity teams to ensure accurate claim adjudication.
- Document and maintain claim processing instructions and workflows to ensure accurate and efficient processing.
- Provide guidance and mentoring to Claims Liaison Specialists.
- Analysis & Reporting
- Perform root-cause analysis of claim errors, payment delays, and provider/member complaints.
- Compile and present findings to leadership with recommended solutions.
- Track claim trends and prepare reports on recurring issues, financial impact, and compliance risks.
- Stakeholder Communication
- Provide clear and timely communication of claim resolutions to providers, members, and internal stakeholders.
- Develop strong working relationships with provider relations, customer service, utilization management, and network management teams.
- Function as a subject-matter resource on claim workflows and policies.
- Process Improvement & Compliance
- Identify opportunities to improve claims workflows, system configuration, and provider/member experience.
- Participate in cross-functional workgroups to implement corrective actions and process enhancements.
- Ensure adherence to state, federal, and accreditation guidelines (e.g., CMS, HIPAA, NCQA).
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
#LI-Hybrid