Job Description

Responsibilities:

• Assist and educate 1199SEIU members and providers with out of network fees and out of pocket expenses on the contracts and benefits of using the Funds network
• Negotiate and resolve large volume of complex, high dollar balance billing inquires fees and discounts for members with non-participating providers via telephone and written correspondence; maintain ongoing communication with providers, members, attorneys, or collection agencies to resolve balance billing/fee negotiation inquiries
• Proactively negotiate claims impacted by the No Surprises Act (NSA), focusing on resolving disputes with out-of-network providers to avoid escalation to Independent Dispute Resolution (IDR). This includes leveraging communication and negotiation strategies to achieve mutually agreeable payment solutions. Assess claim details and potential outcomes to determine when negotiation is more beneficial than escalating to IDR, utilizing various benchmarks.
• Oversee and update internal channels to ensure access to accurate information regarding Balance Billing requirements
• Utilize the various databases to assess and compute reasonable rates, negotiating claim payments with providers, attorneys, and collection agencies on behalf of members.
• Assist in developing and maintaining reporting structures for NSA claims, tracking key metrics such as settlement rates, cases escalated to IDR, and overall compliance with NSA guidelines.
• Assist in generating and presenting detailed reports on NSA-related claim outcomes, including the volume of claims negotiated successfully, claims escalated to IDR, and resolution timelines, providing these insights to management for strategic planning.
• Contribute to developing, maintaining, and monitoring tracking databases to enhance the Balance Billing Department's functions and improve overall workflow efficiency.
• Assist in training new and current staff on balance billing and fee negotiation procedures to meet department performance standards.
• Collaborate closely with the Manager of Balance Billing Fee Negotiation to track, report, and achieve departmental goals.
• Proactively identify and communicate any barriers to achieving departmental objectives to management.
• Support management in coordinating and executing Balance Billing Department workflow initiatives and projects.
• Assist in preparing and presenting daily, weekly, and monthly tracking reports to management, highlighting key trends and outcomes.
• Conduct research and provide recommendations for process improvements, enhancing the efficiency and effectiveness of operations.
• Perform special projects and other duties as assigned by management.

Qualifications:

• Associates degree or the equivalent years’ experience.
• Minimum three (3) years hospital and medical claims processing experience and minimum two (2) years of negotiation experience required
• Excellent knowledge of health claims, eligibility rules, Coordination of Benefits (COB)
• Familiarity with the No Surprises Act (NSA): Comprehensive knowledge of NSA regulations, including experience navigating surprise billing protections, Independent Dispute Resolution (IDR) processes, and the Qualified Payment Amount (QPA).
• Excellent critical thinking, attention to detail and problem-solving skills; able to work well independently and as a team player. Demonstrate analytical and organizational skills with ability to multi-task and meet operational deadlines
• Excellent math skills and the ability to translate mathematical information into concise reports. Ability to conduct various data comparison analysis, working knowledge of macros, tables, forms, queries and reports necessary
• Proficiency in Microsoft Office (Word, Excel, Access, Outlook etc.). Ability to grasp and utilize new software systems
• Ability to work well under pressure, maintain professional manner and presentation