Appeal Resolution Specialist jobs in Troy, NY

Job Overview:

We are seeking a detail-oriented and experienced Claims Resolution Specialist to join our dynamic team. This role is crucial for assisting covered members of Group Health Insurance plans in resolving claims issues at the point of service. The ideal candidate will have a deep understanding of Medicare and commercial health benefit plan billing guidelines and possess excellent problem-solving skills. Your expertise in medical billing, documentation, and terminology will be crucial in this role.

Responsibilities:

- Review and analyze medical records, eligibility records, bills, explanation of benefits, and other relevant documentation to determine the validity of insurance claims, and to resolve claims issues for Medicare and commercial insurance plans.

- Verify insurance coverage and eligibility for claimants

- Maintain strict confidentiality of patients' protected health information in accordance with HIPAA regulations.

- Assist in generating special reports and track problem medical claims according to HIPAA guidelines.

- Adhere to HIPAA guidelines for handling and processing sensitive information within these claims.

- Utilize a documentation system to track both incoming and outgoing inquiries effectively.

- Interpret major carrier health plan contract language, including riders and schedules.

- Communicate effectively, both verbally and in writing, with members, providers, pharmacists, and other stakeholders, ensuring professional interaction at all times.

- Provide quick and accurate resolution to claims issues, escalating urgent matters as necessary and monitoring their status.

- Manage multiple tasks efficiently, adhering to deadlines while maintaining production and quality standards.

- Utilize knowledge of medical coding systems such as ICD-9 and ICD-10 to understand claims billing and identify potential conflicts resulting in denied claims

- Collaborate with healthcare providers, insurance companies, and legal professionals to resolve claim disputes

- Stay updated on changes in healthcare regulations, including Medicare guidelines

- Provide exceptional customer service by addressing inquiries and concerns related to claims

Qualifications:

- At least two years of customer service experience, preferably in healthcare or insurance settings.

- Strong working knowledge of Microsoft Office Suite, particularly Microsoft Word.

- Demonstrated ability to analyze, solve, and communicate complex issues related to benefits, claims processing, and billing.

- Proven ability to adhere to strict confidentiality guidelines and handle sensitive information with discretion.

- Excellent attention to detail and the capability to meet established quality and productivity standards.

- Preferred experience with documentation systems for tracking inquiries.

- Proven experience as a Claims Specialist or similar role in the healthcare industry

- In-depth knowledge of medical billing processes, and plan design.

- Familiarity with medical terminology and documentation practices

- Strong understanding of insurance verification procedures

- Proficient in using relevant software.

- Excellent attention to detail and analytical skills

Skills:

- Strong analytical and problem-solving skills.

- Exceptional communication skills, both written and verbal.

- Time management skills with the ability to manage multiple priorities.

- Strong organizational skills and attention to detail.

Education:

• A high school diploma is required; a bachelor’s degree in a relevant field is preferred.

Note: All positions at our company are paid positions.

Job Type: Full-time

Pay: $50,000.00 - $55,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off

Schedule:

• 8 hour shift
• Monday to Friday
• No weekends

Work setting:

• In-person
• Office

Ability to Relocate:

• Wynantskill, NY 12198: Relocate before starting work (Required)

Work Location: In person