Claims Resolution Representative 2

<strong>At CNSI, we strive to be the market leader and most trusted partner for innovative and transformative technology-enabled solutions that improve health outcomes and reduce costs. We&rsquo;re passionate about helping our clients improve the health and well-being of individuals and families. We succeed when our clients succeed.</strong>

Cheyenne, WY


<strong>CNSI delivers a broad range of health information technology enterprise solutions and customizable products to a diverse base of state and federal agencies. We align, build, and manage innovative, high-quality, cost-effective solutions that help customers achieve their mission, enhance business performance, reduce costs, and improve health for over 51 million Americans.</strong>

keywords: summary,analysis,claims,analysis,performance,implementation,notify,research,knowledge,values,experience,education,skills,compensation


Overview: Claims Resolution Representative 2 will assist with bill-specific research to resolve outstanding issues and provide guidance in a variety of duties according to the Wyoming Department of Health. This position is responsible for accurate and timely research of all claim dispute types, timely processing of adjustments, and acts as a liaison between members, providers, and the internal claims department. Will also determine if a recalculation is warranted and modification to the payment amount is necessary. This position is in Cheyenne, Wyoming.
Responsibilities: <ul> <li>Independently resolve suspended claims using the resolution screens in accordance with operational procedures and process recoupments.</li> <li>Determine when to use a "Forcible" disposition to override the edit and process the claim based on operational claims adjudication procedure.</li> <li>Review and analyze claims and follow up on the status of claims and reimbursement; ensure accuracy and consistency of claims processing; eliminate the back and forth with the Provider when correcting a claim.</li> <li>Interpret and apply policy and reimbursement rules to support provider inquiries.</li> <li>Approve or deny requests for transportation authorization from providers, verifying member transportation claims, and process approved claims.</li> <li>Identify areas for provider education to promote provider claims correction on their first response and communicate these to management and Field Representatives.</li> <li>Fix errors or inconsistencies as they are identified and notify staff member(s), when applicable, and re-train or corrective action as required.</li> <li>Train on operational procedures and review operational procedures and standard management practice.</li> <li>Independently research and resolve medical bill data, making necessary corrections of information by comparing data with source documents to identify root causes; request additional information needed to complete adjudication of bills.</li> <li>Research and review submitted bills (paper or electronic) requesting adjustment consideration, and process according to Wyoming Department of Health policies and procedures; make the appropriate bill adjustment into the claims system according to contractual requirements and timelines.</li> <li>Perform manual pricing and audit checks to ensure compliance with Wyoming policies and rules; perform manual reviews on claims, documents, and attachments; review and process suspended claims and submitted documentation.</li> <li>Facilitate manual entry of claims into the system; research and electronically track suspended claims; provide enough detail on claims denial reasons.</li> <li>Release individual claims for providers on review; independently re-submit claims with applicable corrections, and address discrepancies in charges, payments, adjustments, and demographic information.</li> <li>Implement workflow processes and capabilities for work queues with the ability to route workstreams between CNSI and the state; assist the state in simplifying business rules and policies.</li> </ul>
Requirements: <ul> <li>You have a High School diploma or GED with at least two (2) to five (5) years&rsquo; experience conducting research to resolve issues within the healthcare field.</li> <li>You are available to work from 7:00 AM to 6:00 PM Mountain Time on all State business days, Monday through Friday (excluding Wyoming State holidays).</li> <li>You have expert knowledge of claims and medical terminology including medical diagnosis and procedure codes, and claims pricing methodologies such as DRG, manual pricing, and fee for service experience.</li> <li>You have knowledge of medical bill/claims forms, ICD-9/10CM coding, CPT coding, bill forms, and other medical coding schemes (certification desired).</li> <li>You can simultaneously maneuver through various computer claims and eligibility platforms.</li> <li>You have strong computer skills (MS Word and Excel).</li> <li>You have outstanding customer satisfaction skills, can work well with others, and dependable in both production and attendance.</li> <li>You have excellent oral and written communication and organization and time management skills and can establish priorities effectively.</li> <li>You can read, write and follow directions and are self-directed and capable of working without direct supervision.</li> <li>It is strongly preferred if you have medical billing software experience, demonstrated knowledge of third-party billing procedures, knowledge of claims review and analysis, and knowledge of Medicare and Medicaid.</li> </ul> <br /> <p><strong><em>About Us:</em></strong></p> <p>At CNSI, we strive to be the market leader and most trusted partner for innovative and transformative technology-enabled solutions that improve health outcomes and reduce costs. We&rsquo;re passionate about helping our clients improve the health and well-being of individuals and families. We succeed when our clients succeed.</p> <p>Innovation and commitment to our mission are core to our DNA. And through our shared values, we foster an environment of inclusion, empowerment, accountability and fun! You will be offered a competitive compensation and benefits package.</p> <p>CNSI is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, marital status, genetic status, family responsibilities, protected veteran status or any other status protected by applicable Federal, State, or Local Law. We are proud of our diversity and encourage all qualified applicants to apply.</p>