Job Description

Posted Date: 5/10/2019

Position Purpose: Provide the reason the position exists in this space and its primary objective.

  • The Resolutions Center Coordinator researches, identifies root cause and implements resolution(s) for all provider issues regarding claims adjudication. The Resolutions Center Coordinator will ensure both root cause resolution and reprocessing of appropriate claims. The Resolutions Center Coordinator will have ability to ensure the claims processing system is setup correctly for benefits, prior authorization, provider demographics and fee schedule(s). The Resolutions Center Coordinator will participate in identifying trends, automation opportunities, as well as recommendations for staff training.
  • Resolutions Center Coordinators will be responsible to maintain the provider demographic information in claims processing system(s) or other database that “feeds” to the claims processing system(s), inclusive of new and updated demographics, banking information and fee schedules.
  • Resolutions Center Coordinators will be responsible to ensure claims processing system(s) are setup accurately, inclusive of the plan master, benefit structure and claims processing rules, across multiple lines of business. Resolution Center Coordinators will be responsible to load and test enhancements or other required testing for system upgrades, data loads and/or auto adjudication. Auto adjudication may be identified as claims system auto adjudication or robotic processing automation.
  • Resolution Center Coordinators will be responsible for appropriate verbal and written communication directly with providers, this may include inbound and outbound calling. Resolution Center Coordinators will communicate with internal Departments who may communicate with providers. Resolution Center Coordinators may be requested to attend provider Joint Operating Committees.
  • Resolutions Center Coordinators will be responsible for the appropriate adjustment of claims, once root-cause is identified and verified. Adjustments may include, but are not limited to, refunds, voids, paid claims, denied claims. Resolution Center Coordinators will ensure the root-cause of an improperly adjudicated claim is identified and resolved. Additionally, the Resolutions Center Coordinator will identify whether additional claims have been improperly adjudicated.

Education:

  • High school diploma
  • Associates or higher college preferred

Years of Experience:

  • 2+ years of managed care experience, inclusive of one or more of the following: claims, resolutions, encounters, system configuration, call center, provider relations
  • Provider billing experience may be substituted for managed care experience

Work Related Experience:

  • Claims processing, information systems, customer service, call center, provider relations

Specialized Knowledge:

  • Claims processing systems
  • Managed care systems, including provider setup and benefits
  • Provider reimbursement cycle

Application Instructions

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