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Claims Resolution Spec - CS9109NS-MARICOPA
Job Number:
26943555
Company Name:
Magellan Health Services
Job Location:
Phoenix, AZ US
Job Category:
Healthcare & Medical
Claims Resolution Spec - CS9109NS-MARICOPA
Claims Resolution Spec - CS9109NS-MARICOPA
Requisition ID 7144 Full/Part Time Full-time
Location
Phoenix
AZ
Description JOB SUMMARY The Claims Resolution Specialist serves as the claims functional ex- pert within the CMC. The specialist uses this expertise to aid others in the CMC in the interpretation of claims payment. When claims issues cannot be resolved by others in the CMC or the amount of time involved in claims problem resolution is anticipated to be excessive, claims issues are escalated to the Resolution Specialist. The Specialist has the responsibility for accurate and timely claims research of all claim types. When a recalculation is warranted and modification to the payment amount is determined to be required, acting within established parameters, the Specialist will make the appropriate payment adjustment in the claims system. When a payment adjustment is outside the scope of the Specialist or the degree of complexity necessitates, the Specialist will coordinate resolution of issues with the Claims Department. The Specialist will ensure that documentation is made in the appropriate system to ensure all pertinent information is recorded both for ease of resolution by the Claims Department and service continuation for the customer. When appropriate, the Resolution Specialist will update members and pro- viders with the disposition of payment. When call volume warrants, this position will also have responsibility of serving calls from mem- bers and providers with inquiries as they relate to eligibility, benefits, claims, authorization of services and other Magellan products and services. As the resident claims expert, the Claims Resolution Specialist may be called upon by the Learning and Development Team, Supervisors or others in the CMC to aid in CMC education activities.
ESSENTIAL FUNCTIONS (Tasks critical to completion of daily workload)
A. Researches claims status, provider reimbursement check tracing, requests reissuance of Explanation of Benefits (EOB), researches and resolves EAP ad hoc claims, makes claims adjustments within established parameters. Maintains research tracking log of claims issues. Maintains claims data entry error and TAT QI report.
B. Provides back-up and additional support to customer service representatives as warranted by needs of service. Research- es and provides information regarding member eligibility, benefits, EAP services, claim status, and authorization inquiries to callers while maintaining confidentiality..
C. Documents calls and forwards required information to the ap- propriate staff. Coordinates with Corporate Claims as re- quired.
D. Serve as CMC claims subject matter expert and assist in education of colleagues.
NON-ESSENTIAL FUNCTIONS (Additional tasks necessary to meet overall performance standards)
Performs various other duties and special projects that are assigned on a daily basis while performing their primary function.
SERVICE DELIVERY EXPECTATIONS: One must be customer service oriented, team player, maintain mem- ber and provider confidentiality at all times, demonstrate effective problem solving skills, and be punctual and maintain good attendance.
MINIMUM REQUIREMENTS (Skills necessary to meet minimum performance standards of the position)
1. Education: HS/GED 2. Experience: 1-3 years: Customer Service 3. Computer Skills: Must be a proficient typist, knowledgeable of MS Excel and able to maneuver through various other computer application claims and eligibility platforms while verifying demographic information on all calls.
OTHER: Excellent verbal and written communication skills, organizational skills required and the ability to handle multiple tasks. Must demon- strate professional call handling skills while under stress. Must be flexible in scheduling and have the ability to accept change
PREFERRED QUALIFICATIONS (Additional skills necessary to exceed minimum performance standards)
1. Education: BA in Psychology, social services, health ad- ministration, business 2. Experience: Experience in a Customer Service/Call Center/ Health Care/Claims Processing environment
