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.

Qualifications