Job Description

1. Claims Resolution & Support
   
   • Serve as the primary liaison for complex escalated claim inquiries from providers, members, account management, and internal departments.
   • Research and resolve complex claim discrepancies, denials, adjustments, and payment issues within established service-level agreements (SLAs).
   • Coordinate with claims examiners, configuration, and payment integrity teams to ensure accurate claim adjudication.
   • Document and maintain claim processing instructions and workflows to ensure accurate and efficient processing.
   • Provide guidance and mentoring to Claims Liaison Specialists.
2. Analysis & Reporting
   
   • Perform root-cause analysis of claim errors, payment delays, and provider/member complaints.
   • Compile and present findings to leadership with recommended solutions.
   • Track claim trends and prepare reports on recurring issues, financial impact, and compliance risks.
3. Stakeholder Communication
   
   • Provide clear and timely communication of claim resolutions to providers, members, and internal stakeholders.
   • Develop strong working relationships with provider relations, customer service, utilization management, and network management teams.
   • Function as a subject-matter resource on claim workflows and policies.
4. Process Improvement & Compliance
   
   • Identify opportunities to improve claims workflows, system configuration, and provider/member experience.
   • Participate in cross-functional workgroups to implement corrective actions and process enhancements.
   • Ensure adherence to state, federal, and accreditation guidelines (e.g., CMS, HIPAA, NCQA).
5. Performs all other miscellaneous responsibilities and duties as assigned or directed.

#LI-Hybrid

Qualifications

1. Associates degree and three years of related work experience; or equivalent combination of education and related work experience.
2. Effective written and verbal communication skill, including the ability to communicate and present complex issues in a concise and easy to understand manner.
3. Knowledge of process improvement methodologies.
4. Knowledge of methodologies for driving increased operational quality.
5. Intermediate knowledge of Microsoft Office applications including, but not limited to Word, Powerpoint, Outlook and Excel.