- Monitor and report on performance of current claims packages
- Support claims editing escalated provider disputes/appeals and provide guidance across all areas of the company with regards to claims editing and proper coding, billing, and payment.
- Support continuous improvement and quality initiatives to improve processes across departments
- Review and respond to written provider disputes, clearly and articulately outlining the payment discrepancy to the provider
- Thoroughly research post payment claims and take appropriate action to resolve identified issues within turnaround time requirements and quality standards
- Navigate state-specific websites and compare to current payment policy configuration in order to resolve the providers’ payment discrepancy.
- Review medical records to ensure coding is consistent with the services billed and compare against the clinical coding guidelines in order to decide if a claim adjustment is necessary
- Process claim adjustment requests following all established adjustment and claim processing guidelines
- Identify and escalate root cause issues to supervisor for escalated review