POSITION SUMMARY:  The Claims Resolution Specialist is responsible for applying fundamental knowledge of the healthcare revenue cycle practices and procedures as it relates to researching, analyzing, and resolving claims. This job requires regular outreach and assistance to the Monida members and payers. Must be accountable for maintaining accurate records of correspondence with providers and payers. This position is responsible for examining and researching denied and potentially underpaid claims, when necessary.  The position serves as an escalation resource to the Monida members and payers and acts as the liaison. Must demonstrate strong independent judgment in evaluating the claims processing and reporting the status back to the provider and/or payer in a timely fashion. This position also works with the payers on demographic updates, new provider additions/deletions, etc.  Coding knowledge, and payer fee schedule experience is desired. This is a non-exempt position. 

SUPERVISES:  None  

WORKING CONDITIONS:  20-32 hours per week. Schedule is negotiable but hours will be worked during normal business hours of 8am-5pm Monday through Friday at the Monida offices located in Missoula MT.  

ESSENTIAL JOB FUNCTIONS

1. Establishes working relationships with Monida members and payer contacts as a main priority.
2. Receives claim and/or billing issues from Monida members and analyzes the issue per contract terms.
3. Directs correction request of claim and/or billing issues to appropriate parties.
4. Communicates actions taken to member and/or staff and keeps documentation in file for follow-up with member office.
5. Follows-up with member and/or staff to assure results received and completes documentation.
6. Maintains familiarity with contracted payer reimbursement.
7. Meets with members or payer contacts as needed.
8. Provides fees analysis and reporting of analysis at the request of Monida members.
9. Provides RBRVS unit values per CPT codes at the request of members and maintains master spreadsheet.
10. Maintains website look-up tool and master spreadsheet for annual updates.
11. Sends new, updates or term panel form to payers along with monthly roster spreadsheet by payer.
12. Works with the AMA on annual pricing for coding book program and answers any questions for members regarding program.  Works with the Monida Controller on orders. 
13. Maintains updated Fees Authorization Forms from members and ensures current in software to be able to run queries for contracts.
14. Performs proactive reviews of contract reimbursement through provider offices and provides reporting back to the provider office once complete.
15. Informs and educates members involving contracted payer issues via email blasts, newsletters, etc. 
16. Receives input from members regarding reimbursement problems that affect the membership as a whole and works with the involved payer to resolve these problems. Involves other Monida personnel as necessary.
17. Identifies and responds to problematic changes in payer reimbursement policies and/or procedures. 
18. MINIMUM QUALIFICATIONS
    

EDUCATION:    Bachelors degree preferred.

CERTIFICATE/LICENSE:    None required, but CPC or CCS strongly preferred.

EXPERIENCE:    Three years experience in medical billing or coding.