• Research & Resolution Specialist

    Job Locations US-VA-Glen Allen
    Job ID
    2018-4994
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
    By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
     
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
     
    If this sounds like you, read on!

    Overview

    The position is responsible for all research and resolution of claims inquiries and Claims Reconsiderations escalated by provider for all lines of business.  

    Responsibilities

    • Research and resolve claims issues that have been escalated by providers through Claims Reconsiderations and Claims Inquiries that are brought forth by Claims Customer Service, Network Development, and Provider Resolution Managers
    • Research and resolution may include coding/billing issues, systemic claims issues, electronic submissions, and refunds received
    • Coordinate claims resolutions with all appropriate departments in order to resolve issues
    • Process, adjust, and key claims accurately and timely following established guidelines for accuracy, quality, and productivity
    • Identify track and trend claims payment errors in order to determine root causes and actions needed to correct problems. 
    • Identify trends from provider complaints regarding code edits and business decisions that impact claims payments
    • Other miscellaneous duties/activities as assigned
    • The ability to work overtime as needed

    Qualifications

    MINIMUM EDUCATION REQUIREMENTS

    • High School diploma required 

    SPECIAL KNOWLEDGE AND/OR SKILLS

    • Strong communication skills (both verbal and written)
    • Exposure to health care call center environment
    • Ability to conduct research
    • Experience with IDX and QNXT Claim processing systems
    • Ability to work independently as well as in a team environment
    • Strong organizational skills
    • Strong Time Management skills
    • Knowledge of CPT-4, HCPCS coding and ICD10
    • Knowledge of CMS 1500 and UB04 claim forms
    • Ability to meet deadlines and work under pressure 

    WORK BACKGROUND/EXPERIENCE

    • Minimum 3 years claim processing experience, preferably with Medicare/Medicaid 

    PHYSICAL REQUIREMENTS

    • Physical health sufficient to meet the ergonomic standards and demands of the position.

    All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

     

    Our mission is to inspire healthy living within the communities we serve!

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