Claim Resolution Specialist - QC / Pasig

Description

The Claim Resolution Specialist holds a dynamic position within the claims workflow, responsible for submitting appeals to reverse denials and initiate payments, as well as assessing the need for additional actions, such as further appeals or account closures. Individuals in this role may prioritize their tasks based on the complexity of claims and their current workload, ensuring maximum productivity while adhering to compliance and accuracy standards. By effectively managing a high volume of low-balance claims, the specialist guarantees compliance, precision, and revenue recovery that contribute to the success of our clients.

Job Responsibilities:

• Appeal Submission and Resolution: Develop and present comprehensive and convincing appeals for rejected claims, utilizing payer guidelines, contracts, fee schedules, and medical records to resolve issues and facilitate payments.
• Escalation Management: Handle claims escalated by Claim Status Specialists, effectively resolving complex denial situations, including coding disputes, medical necessity challenges, or disagreements with payer policies.
• Underpayment Resolution: Examine and rectify differences between anticipated and actual payments, implementing corrective measures to address underpayments.
• Final Determination: Assess claims to ascertain whether they have been resolved or if further actions are necessary, such as more appeals, escalation, or account closure in accordance with client specifications.
• Account Closure: Review and close accounts after all collection efforts have been exhausted, ensuring thorough documentation and adherence to client guidelines.
• Account Review Feedback: Identify claims that were incorrectly resolved and return them to the relevant team for further review, correction, or training, thus aiding in the enhancement of processes.
• Collaboration: Leverage documentation provided by Document Retrieval Specialists and Claim Status Specialists to carry out resolution activities effectively.

Requirements

•  At least a SHS Graduate or HS Graduate (Old curriculum)
• Must have at least year of experience in healthcare claims management, denial resolution, or appeal writing
• Experience in high-volume, low-balance claims processing is preferred
• Familiarity with payer-specific policies, reimbursement methodologies, and contract terms
• Knowledge of coding principles (e.g., CPT, ICD-10, HCPCS) and medical necessity documentation is an advantage
• Proficient in spoken and written English
• Amenable to work on Graveyard shift
• Amenable to work onsite in Pasig or Quezon City