Dispute Resolution Specialist

JJOB SUMMARY: This role manages an arbitration case load including evaluation of provider disputes and appropriate client payment offers. The incumbent will coordinate efforts with the team and leadership to bring matters to efficient and successful outcomes. The incumbent's primary responsibility will be responding to oversee and manage the intake, processing and coordination of all materials and information relating Independent Dispute Resolution ("IDR") as regulated by Federal or state law.

JOB ROLES AND RESPONSIBILITIES:

1. Prepare written analyses of disputed provider/health plan positions and persuasively document arguments supporting client positions in arbitration packages pursuant to federal regulations.

2. Conduct due diligence (e.g. online research, portal and application research) to assist with the analysis and preparation of arbitration packages.

3. Works with other departments to develop or obtain information necessary for the submission of IDR packages.

4. Review and analyze clinical information along with documents submitted by providers of moderate to high complexity.

5. Meet federal filing deadlines and turn around times

6. Respond timely to all electronic, written and verbal communications, log information derived from written and verbal communication; maintain detailed and accurate records.

7. Outreach to clients for data needed for arbitration packages

8. Maintain department productivity and quality standards

9. Sensitivity to privacy in accordance with HIPAA guidelines

10. Collaborate, coordinate, and communicate across disciplines and departments.

11. Ensure compliance with HIPAA regulations and requirements.

12. Demonstrate Company's Core Competencies and values held within.

13. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

JOB SCOPE:

Keep the needs of external and internal customers as a priority when making decisions and taking action. Operates independently under limited supervision. Has decision making authority within specified parameters and must engage with manager for advice and/or help to proactively resolve cases. Works across customers, beneficiaries, providers, and supplemental payors while maintaining positive relationships.

JOB REQUIREMENTS (Education, Experience, and Training):

• Minimum high school diploma or equivalent (GED) and two (2) years' experience in healthcare operations. Bachelors' degree in a related field is preferred plus two (2) years' experience in healthcare operations.

• Excellent organizational, analytical and independent decision-making skills

• Demonstrated problem solving skills with the ability to manage multiple priorities and meet associated timelines

• Ability to anticipate needs and solve problems proactively in a fast paced, rapidly changing environment

• Sound business judgement

• Ability to learn quickly and work independently within time constraints

• Adept knowledge of Microsoft Word, Excel and Outlook

• Logical, clear and concise written and verbal communication skills

• Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone

COMPENSATION

The salary range for this position is $18 per hour. Specific offers take into account a candidate's education, experience and skills, as well as the candidate's work location and internal equity. This position is also eligible for health insurance and 401k.

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Why Claritev?

Healthcare is complex. We help make it clearer.

At Claritev, you'll do work that matters. Together, we're helping make healthcare more transparent and affordable for all through the power of data, technology, and expertise. We offer meaningful opportunities to grow your career, collaborate with talented colleagues, and make an impact on the clients and communities we serve. If you're looking for purpose, growth, and a team that succeeds together, you'll find it here.

What Guides Us

At Claritev, innovation, agility, and a focus on results drive our success. We embrace bold thinking, work as one team, take ownership, and strive for excellence in everything we do - creating meaningful impact for our clients, communities, and each other.