Job Description

Our Mission:  Provide the best value in health insurance and related health services to improve the quality of life for Arizonans.

Our Vision: 

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

Education:   

  • High school or GED
  • College preferred

Years of Experience:  

  • 3+ years of claims processing

Specialized Knowledge:  

  •  ICD10/HCPC/CPT/ADA
  • 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

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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