Claims Resolution Specialist

About Claritev

Claritev is a progressive team of innovative professionals committed to reducing healthcare costs for all stakeholders. We foster a culture of accountability, diversity, innovation, and mutual support to unlock our combined potential and lead advancements in healthcare technology, data, and innovation.

Position Overview

The Claims Resolution Specialist I is tasked with engaging healthcare providers to negotiate eligible claims within a specified dollar range before payment. The goal is to secure the maximum possible discounts and cost savings on behalf of our clients.

Primary Responsibilities

• Handle a large volume of healthcare claims meticulously to optimize savings, adhering to production standards and individual targets by communicating with providers and proposing solutions with quality assurance.
• Conduct provider research to substantiate desired savings.
• Respond to counteroffers and work to resolve claims in line with client policies and guidelines.
• Pursue savings opportunities with providers previously challenging to negotiate.
• Establish and maintain ongoing agreements for current and future claims.
• Maintain and update the provider database to support claims processing.
• Regularly initiate calls with providers to negotiate, overcome objections, and close agreements, spending up to 40% of time on phone interactions.
• Educate providers about the online provider portal available for reviewing and approving proposals.
• Achieve and sustain departmental performance metrics.
• Manage post-claim service inquiries including payment status and defending negotiated terms.
• May have responsibilities involving automatic call distributor (ACD) phone handling and tracking outcomes.
• Collaborate effectively with cross-functional teams and departments.
• Ensure strict compliance with HIPAA regulations.
• Uphold company core competencies and values.
• Note: Due to handling sensitive PHI data, this is classified as a high-risk position.
• The duties listed are not exhaustive; additional responsibilities may be assigned as required.

Experience and Skills Required

• At least a high school diploma or GED.
• Minimum six months of experience in healthcare-related sectors such as provider billing, medical coding, collections, insurance, or managed care.
• State licensure certification (e.g., NY Health or P&C State Adjustor license) may be needed; if hired uncertified, certification must be obtained within six months or alternative employment actions may occur.
• Knowledge of applicable laws and statutes related to workers' compensation or auto medical bills is advantageous.
• Familiarity with general office procedures and medical insurance claim forms.
• Strong verbal, written, and listening communication skills, as well as expertise in negotiation, teamwork, and organization.
• Ability to interpret verbal and written instructions clearly.
• Professional demeanor with appropriate telephone etiquette and business communication language and tone.
• Ability to deliver customer service at expected standards with attention to detail and accuracy including calculations.
• Capable of identifying issues and determining corrective actions efficiently.
• Effective workload organization to meet deadlines and adapt to changing priorities in a fast-paced environment.
• Ability to work independently and safeguard confidential information.
• Competent in using job-related software and hardware such as MS Word, Excel, and databases.
• Able to perform standard office tasks involving prolonged periods of computer work and use of office equipment like telephones, copiers, and keyboards.

Compensation & Benefits

This role offers an hourly wage of $20.23, with exact pay dependent on education, experience, skills, and location, plus internal equity considerations. Benefits include medical, dental, vision coverage, life insurance, disability plans, paid parental leave, 401(k) with match, employee stock purchase plan, generous paid time off, holidays, tuition reimbursement, flexible spending accounts, employee assistance programs, and sick leave accrual according to state law.

Additional Information

Claritev is committed to equal employment opportunities without discrimination. Employment consideration is provided regardless of age, race, color, religion, gender, sexual orientation, gender identity, national origin, disability, or veteran status.

Applications will be accepted for a minimum of five days from posting or as long as the position remains open.