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Job Requirements of Claims Research & Resolution Representative 2:
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Employment Type:
Contractor
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Location:
Wisconsin, US (Onsite)
Do you meet the requirements for this job?
Claims Research & Resolution Representative 2
Careers Integrated Resources Inc
Wisconsin, US (Onsite)
Contractor
Coordinate exchange of provider information with appropriate iCare vendors (claims, pharmacy, subrogation and cost saving.
Respond in a timely fashion to provider questions and issues regarding claims payment, in the form of review reopening s, reconsiderations, and member bills.
Interface with iCare/Cognizant personnel to establish and document claims processing, pricing and network policies and procedures.
Provide prompt, courteous and excellent service to internal and external customers.
Research and examine problem claims to determine the cause of the claim s problem status. Escalate trends and educational opportunities to the appropriate contacts.
Exercise proper judgement on questionable claims (i.e. timely filing and high dollar exceptions).
Provide input and make recommendations for solutions to departmental and interdepartmental problems.
Understand the complexity of the enrollment, benefit and authorization process as it relates to claims.
Assist with the documentation of interdepartmental procedures.
Participate in claims related audits initiated by the State, CMS or outside vendors.
Review IAR s generated by enrollment and submit to Cognizant accordingly, verifying adjustments have been made and closing the loop with all parties involved.
Perform various administrative support duties not limited to mailings, scanning and forwarding of claims.
Maintain proficiency in department queues.
Required Qualifications:
1-3 years claims experience in an HMO or health insurance environment.
Experience analyzing all facets of complex claim situations and resolving them.
Proficiency with Microsoft Office applications, including Excel, Word, and Outlook.
Working knowledge of medical terminology, CPT-4 procedures, ICD-9 diagnosis codes, and DRG experience
Preferred Qualifications:
1-3 years of experience in a claims processing system.
Experience with multiple product lines (HMO, Medicaid, and Medicare).
1-2 years of experience as a Customer Service or Provider Service Representative.
Additional Information
Workstyle: Home. Home workstyle is defined as remote but will use Client office space on an as needed basis for collaboration and other face-to-face needs.
Typical Work Days/Hours: Monday - Friday, 8:30am - 5:00pm Central Standard Time (CST)
Nationwide Remote - This is a remote nationwide position.
WAH Internet Requirements
To ensure Home or Hybrid Home/Office employees ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
Satellite, cellular and microwave connection can be used only if approved by leadership.
Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Client will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Respond in a timely fashion to provider questions and issues regarding claims payment, in the form of review reopening s, reconsiderations, and member bills.
Interface with iCare/Cognizant personnel to establish and document claims processing, pricing and network policies and procedures.
Provide prompt, courteous and excellent service to internal and external customers.
Research and examine problem claims to determine the cause of the claim s problem status. Escalate trends and educational opportunities to the appropriate contacts.
Exercise proper judgement on questionable claims (i.e. timely filing and high dollar exceptions).
Provide input and make recommendations for solutions to departmental and interdepartmental problems.
Understand the complexity of the enrollment, benefit and authorization process as it relates to claims.
Assist with the documentation of interdepartmental procedures.
Participate in claims related audits initiated by the State, CMS or outside vendors.
Review IAR s generated by enrollment and submit to Cognizant accordingly, verifying adjustments have been made and closing the loop with all parties involved.
Perform various administrative support duties not limited to mailings, scanning and forwarding of claims.
Maintain proficiency in department queues.
Required Qualifications:
1-3 years claims experience in an HMO or health insurance environment.
Experience analyzing all facets of complex claim situations and resolving them.
Proficiency with Microsoft Office applications, including Excel, Word, and Outlook.
Working knowledge of medical terminology, CPT-4 procedures, ICD-9 diagnosis codes, and DRG experience
Preferred Qualifications:
1-3 years of experience in a claims processing system.
Experience with multiple product lines (HMO, Medicaid, and Medicare).
1-2 years of experience as a Customer Service or Provider Service Representative.
Additional Information
Workstyle: Home. Home workstyle is defined as remote but will use Client office space on an as needed basis for collaboration and other face-to-face needs.
Typical Work Days/Hours: Monday - Friday, 8:30am - 5:00pm Central Standard Time (CST)
Nationwide Remote - This is a remote nationwide position.
WAH Internet Requirements
To ensure Home or Hybrid Home/Office employees ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
Satellite, cellular and microwave connection can be used only if approved by leadership.
Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Client will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
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