Reimbursement and Complex Claims Analyst

The Phia Group is a service oriented consultant that assists health plans nationwide and internationally We provide our clients with innovative cost cutting solutions and service offerings We continue to enjoy growth thanks to our most valuable resource our talented and committed team As employers and payers seek to identify reasonable prices for healthcare while protecting employees and members against abusive practices they encounter conflicts from many directions Areas of emphasis include the clinical and coding aspects of claims and balance billing the practice by some providers of medical services to seek payment of amounts in excess of payments made by health plans from patients andor employers The Reimbursement and Complex Claims Analyst will negotiate agreements including pre service and pre claim with facilities and providers for domestic and international clients while supporting the reimbursement team with daily operational tasks The role will also assist with complex and high dollar claim matters and support research client configurations implementations and process improvement This position requires someone who is proactive persuasive persistent respectful and assertive with excellent problem solving communication and data literacy skills The candidate must be comfortable multitasking and working in a dynamic fast paced environment Essential Duties and Responsibilities include the following Other duties may be assigned Negotiate agreements with facilities and providers to establish appropriate reimbursement terms before services are rendered or claims are submittedManage a daily running inventory of pre service requests pre claim matters unpaid claims and claim disputesReview and prioritize matters based on processing criteria timelines client demands financial exposure and service level standardsContact facilities and providers to discuss proposed reimbursement arrangements charge adjustments payment terms and supporting rationaleDraft correspondence and agreements pertaining to negotiation and settlement efforts for providers and other entitiesCapture detailed notes on calls and negotiations for future reference by internal teams external clients providers and collection officesHandle complex and high dollar claims under sensitive timelines and appropriately escalate client issues or concerns involving high touch negotiationsWork with the Provider Relations escalation team and The Phia Groups legal department to ensure proper handling and escalation of complicated mattersSupport the reimbursement team with daily repricing research claim review system updates and operational tasksMaintain the integrity of the centralized data repository including fee schedules crosswalk tables and other data sources essential to repricing operationsParticipate in maintaining client configurations and supporting new client implementationsParticipate in specialized projects focused on coding benchmarking reimbursement and clinical considerationsMaintain and update standard operating procedures under the guidance of Provider Relations managementProperly handle confidential information in accordance with the Health Insurance Portability and Accountability Act HIPAAExperience and Qualifications Preferred Baccalaureate degree BABS from an accredited college or universityPreferred AAPC Certified Professional Coder CPC credential or comparable coding and reimbursement expertiseExperience in a medical healthcare claims role preferably involving negotiation reimbursement repricing or complex claims or experience at an insurance company third party administrator or hospital with emphasis in claims fee schedules or contractingKnowledge of healthcare reimbursement methodologies fee schedules medical coding and provider contracting conceptsStrong oral and written communication negotiation organization and problem solving skillsStrong data literacy skills with the ability to triage organize and interpret multiple data sourcesComputer literate including Microsoft Office products Working Conditions Physical Demands Sitting at a workstation for prolonged periods of time Extensive computer work Workstation may be exposed to overhead fluorescent lighting and air conditioning Fast paced work environment Operates office equipment including personal computer copiers and fax machines This job description is not intended to be and should not be construed as an all inclusive list of all the responsibilities skills or working conditions associated with the position While it is intended to accurately reflect the position activities and requirements the company reserves the right to modify add or remove duties and assign other duties as necessary External and internal applicants as well as position incumbents who become disabled as defined under the Americans with Disabilities Act must be able to perform the essential job functions as listed here either unaided or with the assistance of a reasonable accommodation to be determined by management on a case by case basis The Phia Group LLC