The Contestation Specialist serves as the point of contact between high risk provider and payors to ensure claims processing issues in which financially impact the value share partnership. Identify and resolve internal, systematic contestation-related issues.
ESSENTIAL JOB DUTIES/RESPONSIBILITIES:
- Identifies internal, systematic missed opportunities to be contested.
- Escalates contested claims opened for more than 91 days to market finance directors to assist with the collection process.
- Maintains tracking log for all payors and keeps management up to date on the progress. Enhances Health Plan audit processes based on key components of each payor’s contracts, products and plans.
- Maintains documents with our internal policies to collect data, research patient’s medical records, submit contestations and confirm claims adjustments.
- Provides management team with changes in the payors’ contestation submission and processing guidelines from all payors.
- Recommends changes to current procedures to improve efficiency of Health Plan audit processes.
- Works directly with multiple payors in multiple markets to support our contestation and audit processes.
- Other duties as assigned or requested by manager.
Additional Job Description
KNOWLEDGE, SKILLS AND ABILITIES:
- Knowledge of Medicare Part A, Part B and Stop loss funding
- Excellent written and verbal communication skills
- Excellent collaboration skills
- Motivated auditor of claims data from payors
- Demonstrated analytical and problem-solving skills and attention to detail
- Medicare Advantage experience is a plus
- Data analytics and technical skills preferred
EDUCATION AND EXPERIENCE CRITERIA:
- High school diploma or GED
- One (1) to two (2) years of Healthcare claims processing experience is a plus