Resolution & Adjustment Specialist-SCA

Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes - making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra Health is looking for a Resolution and Adjustment Specialist (SCA) to join our growing team.

Job Summary:

The Resolution and Adjustment Specialist will assist with bill-specific research to resolve outstanding issues and provide guidance in a variety of duties according to the applicable State Health Department. This position is responsible for accurate and timely research of all claim dispute types, timely processing of adjustments, and acts as liaison between members, providers, and internal claims department. Determine if a recalculation is warranted and modification to the payment amount is necessary.

Responsibilities:

• Independently resolve suspended claims using resolution screens in accordance with operational procedures and process requirements.
• Determine when to use a 'Forcible' disposition to override the edit and process the claim based on operational claims adjudication procedure.
• Review and analyze claims and follow up on the status of claims and reimbursement.
• Identify areas for provider education to promote provider claims correction on their first response and communicate these to management and Field Representatives.
• Eliminate the back and forth with the Provider when correcting a claim.
• Interpret and apply policy and reimbursement rules to support provider inquiries.
• Ensure accuracy and consistency of claims processing.
• Fix errors or inconsistencies as they are identified and notify staff member(s), and re-train or correct as required.
• Train on operational procedures and review operational procedures and standard management practice.
• Independently research and resolve medical bill data by comparing data with source documents to identify root causes.
• Request additional information needed to complete adjudication of bills.
• Research and review submitted bills requesting adjustment consideration per Wyoming Dept. of Health policies.
• Make the appropriate bill adjustment into the claims system per contractual requirements.
• Commitment to customer service and operational excellence.
• Perform manual pricing and audit checks for compliance with Wyoming policies.
• Review and process suspended claims and submitted documentation.
• Facilitate manual entry of claims into the system.
• Track suspended claims electronically.
• Provide sufficient detail on claims denial reasons.
• Implement workflow processes and capabilities for routing work queues.
• Assist the state in simplifying business rules and policies.
• Approve or deny requests for transportation authorization and process approved claims.
• Perform manual reviews on claims, documents, and attachments.
• Release individual claims for providers on review.
• Independently re-submit claims with corrections.
• Address discrepancies in charges, payments, adjustments, and demographic information.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.

Required Qualifications

• 3-5 years of experience in claims and medical terminology including diagnosis/procedure codes and pricing methodologies such as DRG/manual pricing.

• Requires knowledge of medical billing/coding forms, ICD-9/10CM coding, CPT coding, and other related systems (certification desired).

• Demonstrated knowledge of third-party billing procedures.

• Requires experience with medical billing software.

• Must be able to work onsite at our Tallahassee, FL or El Paso, TX office
• Must be willing and able to pass a DOL background check

Preferred Qualifications

• Knowledge of claims review and analysis
• Knowledge of Medicare and Medicaid
• Strong computer skills (MS Word and Excel)
• Excellent oral/written communication and organizational skills
• Ability to prioritize and manage time effectively

Why us?

We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.

We do this through our people.

You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.

Benefits

Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.

Thank You!

We know your time is valuable and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may be of interest. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team

Visit us at Acentra.com/careers/

EEO AA M/F/Vet/Disability

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

Compensation

The pay for this position is listed below.

"Based on our compensation philosophy, an applicant's position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level."