Claim Lead Representative, Payer Solutions - Evernorth Health Services- Remote

About the position

This position allows for any work at home location. The role involves researching, analyzing, and calculating claims in accordance with provider contracts. The individual will work with internal matrix partners to resolve pended claims and ticket issues, utilizing the SRS system to route work items to matrix partners and external retailer claim administration staff. Following audit protocols and workflows is essential to ensure quality goals are met. The position also includes special pricing projects as requested by retailers and requires engagement and partnership with supervisors, the claim processing team, and other internal and external partners. Excellent interpersonal skills are necessary to understand and interpret policy provisions and present report analysis and meaningful findings clearly and concisely. The role involves pricing identification of errors and managing resolution with provider contracting and maintenance internal teams, as well as identifying steps necessary to process a varying complexity of contracts for pricing accuracy.

Responsibilities

  • Researches, analyzes and calculates claims in accordance with provider contracts
  • Works with internal matrix partners to resolve pended claims/tickets issues
  • Utilizes SRS system to route work items to matrix partners and external retailer claim administration staff
  • Follows audit protocols and workflows to ensure quality goals
  • Handles special pricing projects as requested by retailers
  • Partners with matrix organizations to implement high potential process improvements
  • Supports and drives process improvement to enhance claim accuracy outcomes
  • Engages with supervisor, claim processing team, and other internal and external partners
  • Identifies steps necessary to process contracts for pricing accuracy

Requirements

  • 1 year of Payer Solutions claim processing technical knowledge and application
  • Customer Service Driven; ability to meet and exceed internal partner and external customer expectations
  • Accountability in critical thinking and decision-making outcomes
  • Problem solving skills; utilization of technical skills and resources to ensure accuracy of final claim resolution
  • Strong communication skills, both verbal and written
  • Ability to teach, educate, and coach others through a variety of claim complexities
  • Process improvement skills; ability to assess trends, processes, and barriers to drive positive outcomes for claim resolutions
  • Fluent understanding and application of key tools and resources for claim processing
  • Basic knowledge with Word, Excel, PowerPoint, WebEx and Outlook preferred

Benefits

  • Comprehensive health-related benefits including medical, vision, dental, and well-being and behavioral health programs
  • 401(k) with company match
  • Company paid life insurance
  • Tuition reimbursement
  • Minimum of 18 days of paid time off per year
  • Paid holidays
  • Annual bonus plan eligibility
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