PURPOSE The Claims Resolution Specialist will perform inhouse claims adjudication for complex medical claims. The Specialist will work with Management to improve processes and quality of data for adjudication purposes. The Specialist will provide regular reporting to Health Plan leadership and Provider leadership. PRINCIPAL ACCOUNTABILITIES: Performs claims adjudication for complex medical claims. Performs regular auditing. Schedules regular meetings with key provider groups to provide reporting and work through claim resolution issues. Handles provider phone calls and emails regarding claims. Meets productivity standards on the number of adjudicated claims. Researches contract terms/interpretation and compile necessary documentation for denial reason validation. Generates weekly Claims Resolution reports for management in accordance with schedule set by supervisor. Generates weekly Provider Claims Resolution logs for Provider Education purposes. Interfaces with Organization's personnel to include fellow team members, supervisor, managers and customers while maintaining the integrity of claims. Adheres to all federal laws and company policies regarding confidentiality of privileged patient information. Works closely with the Medical Management team on authorization process and auditing. Adheres to company Human Resource policies and understands daily company work requirements. Updates job knowledge by participating in educational opportunities. Enhances organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments. Other duties as assigned NECESSARY QUALIFICATIONS: Required Education/Experience/Skills/Abilities: Minimum of three (3) years of medical claims processing experience; Managed Care experience heavily preferred High School Diploma required; Medical Billing & Coding Certification; BA/BS preferred Ability to travel up to 10% Ability to research Medicaid/Medicare fee schedules for rates. Familiarity and knowledge of APRDRG and EAPG pricing for facility claims Knowledge of Medicaid benefits Ability to present reports to Provider team and Management after researchJob Requirements:Claims Resolution SpecialistA'