Resolution Center Coordinator
Our Mission: Provide the best value in health insurance and related health services to improve the quality of life for Arizonans.
Inspire health in Arizona as the trusted leader in delivering affordable, innovative healthcare solutions.
Our Benefits: Our benefits provide work-life balance and the flexibility you need to be your best. We offer comprehensive medical, dental, and vision coverage; a 401K savings plan; paid holidays and vacations; and much more!
Position Purpose: The Resolution Center and the positions contained there within are responsible for "one-touch" resolution of all provider/member related issues. The Resolution Center is responsible for identifying in all circumstances the root cause of the issue and escalating where appropriate for broader; person, process, or system correction. The Resolution Center will take the lead on all inter and intra-departmental coordination and will ultimately be responsible to ensure issues are taken to completion.
- Researches, identifies root cause and implements resolution(s) for all provider issues regarding claims adjudication
- Ensure claims processing system is setup correctly for benefits, prior authorization, provider demographics and fee schedules
- Identifies trends , automation opportunities and recommendations for staff training
- Maintains provider demographics in the claims processing system or other database that "feeds" to the claim processing system, inclusive of new and updated demographics, banking information and fee schedules
- Responsible to test system upgrades, data loads and auto adjudication or robotic processing automation
- Responsible for appropriate verbal and written communication directly with providers, this may include inbound and outbound calling
- Responsible for the appropriate adjustment of claims, once root-cause is identified and verified. Adjustments may include, refunds, voids, paid claims, denied claims
- Responsible for the appropriate handling of provider/member Grievance, Appeals and Disputes (GAD) which may include maintaining accurate information within the GAD database.
- Responsible to ensure all duties and functions are completed within regulatory and health plan timeframes
Education / Experience / Other Requirements
- High school or GED
- College preferred
Years of Experience:
- 3+ years of claims processing
- Claims processing, inclusive of 1500 and UB
- Medical terminology
- Computer, inclusive of Microsoft Office and proprietary claims systems
- Effective communication, verbal and written
- Medicaid, Medicare, AHCCCCS policies and procedures
- Ability to think analytically and make independent decisions
Job Status: Full Time
Job Reference #: R653