Job Description

Oversight of day-to-day activities of the Resolution Center, including, provider claim issues through CRCTs (claims resolution coordination and tracking); accounts receivable reconciliations/inquiries; PDM (provider data maintenance) management and setup; system configuration architecture, benefit set-up, and auto-adjudication; provider phone representatives (inclusive of in-and out-network); recoupments and recoveries (inclusive of working with TPL and COB vendors). Position is responsible for oversight of Claims Clerk duties, which may include, but not be limited to, specific pended claims reports, RPA (Robotic processing automation) processing, scanning vendor rejections.
Ensure appropriate root-cause identification is made, resolved and impacted claims are reprocessed appropriately. This will include working with Reimbursement Services staff, as well as Intra-Departmental staff, including, but not limited to, Information Systems, Network, Contracting, Call-Center, and Internal Audit. This will also include working directly with providers as requested and appropriate, and may include attendance at Joint Operations Committees. Position is also responsible to look for opportunities for automation, including, but may not be limited to claims system auto adjudication and robotic processing automation (RPA).
Develop and maintain internal tracking of all issues, resolutions and appropriate turn-around-time. Information must be maintained in such a manner as to be able to report, including trending. Position is responsible to ensure timelines and accuracy in regulatory reporting requirements.
Develop and maintain operational policies and procedures, including Desktops in I-REPP. Ensure updates are timely and accurate. In conjunction with Training & Development, ensure appropriate training materials and training sessions are available for all Resolutions Center staff.
Develop and maintain job descriptions for Resolution Center staff, cognizant of the organizational changes and how they may impact Resolutions Center operations. Recommend to leadership changes to operational structure.
  • Must be able to effectively communicate with internal and external customers via telephone and email.
  • Able to accurately receive information through oral and written communication.
  • Able to accurately review data and figures both in hard copy and electronic formats.
  • Able to accurately sort through data and think through issues in a timeΓÇÉpressured environment.
  • Able to maintain a calm and collected presence while addressing the concerns from an internal and external customer
  • Able to accurately learn and retain new information, knowledge and skills.
  • Able to efficiently manage multiple tasks, with varying degrees of priority, at the same time.


  • Bachelor's Degree Preferred

Years of Experience:

  • 3+ years of managed care experience
  • 5+ year of people supervision

Work Related Experience:

  • Claims processing, information systems, customer service call center, provider relations
  • Leadership
  • Reporting and presentations

Specialized Knowledge:

  • Claims processing systems
  • Managed care systems, including provider setup and benefits
  • Trend reporting
  • Provider reimbursement cycle

Application Instructions

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