Senior Claims Response Analyst - Remote

The Sr. Response Analyst role is responsible for the investigation of the referral/authorization episodes to determine approval or nonapproval and respond accordingly to the Home Plans requests.

WHAT YOULL BE DOING 

• Review and Finalize 095 and PDC reports of claims sent to the Home Plan needing review and status of approval and or payment/denial.
• Responsible for reviewing and responding to the email inquiries received from the Home Plans.
• Responsible for reviewing and working on the reconciliations of members out of pocket maximums received from the Home Plans.
• Responsible for reviewing and resolving claim inquiries from internal staff.
• Investigate and analyze the validity of claim appeals and disputes.
• Prepare and submit comprehensive responses to appeals and disputes outlining findings and recommendations.
• Identify root causes of denials or disputes.
• Communicate resolutions to members providers or other stakeholders.
• Responsible for responding to Blue Cross appeals grievances and DOI appeals
• Respond promptly and accurately to inquiries regarding claim status coverage and payment.
• Gather necessary information and documentation to address inquiries effectively.
• Escalate complex inquiries to appropriate personnel when necessary.

Qualifications :

WHAT YOULL NEED TO HAVE

• Minimum 25 years claims processing experience.
• CPT and ICD coding knowledge.
• Ability to read and understand benefit plan descriptions
• Ability to work independently and prioritize tasks to meet deadlines.
• A clear understanding of coding requirements ie: CPT and ICD codes and medical terminology.
• Intermediate to advanced understanding of Microsoft Office products ie: Excel Word Access etc.
• Able to solve problems exercise initiative and make role level decisions.
• Thorough understanding of claims processing compliance requirements.
• Ability to meet deadlines and prioritize tasks and assign work daily to the staff.
• Ability to work independently with minimal supervision.
• Effective written and oral communication.
• Other duties as assigned

WE WOULD LOVE FOR YOU TO HAVE

• Certified Professional Biller (CPB) Certified Professional Coder (CPC) or other similar certifications.
• Prior claims processing experience within Eldorado HealthPac Claims Adjudication System is a plus.

Additional Information :

The salary range for this role will depend on the background and experience of the individual ranging from $45000.00 to $50000 per year.

BENEFITS:

All fulltime employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. While you are hard at work advancing valuebased healthcare we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:

• Work from Home: Guidehealth is a fully remote company providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
• Keep Health a Priority: We offer comprehensive Medical Dental and Vision plans to keep you covered.
• Plan for the Future: Our 401(k) plan includes a 3 employer match to your 6 contribution.
• Have Peace of Mind: We provide Life and Disability insurance for those just in case moments. Additionally we offer voluntary Life options to keep you and your loved ones protected.
• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
• Take Time for Yourself: We offer Flexible Time Off tailored to meet your needs and the needs of the business helping you achieve worklife balance and meet your personal goals.
• Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
• Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.

COMPENSATION:

The listed compensation range listed is paid biweekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include but are not limited to: skill set years of relevant experience education location and licensure/certifications.

OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT 

Diversity inclusion and belonging are at the core of Guidehealths values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race religious creed color age sex sexual orientation and identity national origin citizenship religion marital status familial status physical sensory or medical disability Family and Medical Leave military or veteran status pregnancy childbirth or other related medical conditions or any other classification protected by federal state and local laws and ordinances. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring placement promotion transfer demotion layoff termination recruitment advertising pay and other forms of compensation training and general treatment during employment. 

OUR COMITTMENT TO PROTECTION OF PATIENT AND COMPANY DATA

This position is responsible for following all Security policies and procedures in order to protect all PHI and PII under Guidehealths custodianship as well as Guidehealth Intellectual Properties.  For any securityspecific roles the responsibilities would be further defined by the hiring manager. 

REMOTE WORK TECHNICAL REQUIREMENTS

Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection capable of conducting video calls on camera and connecting to various internal and external systems. The recommended internet speed is a minimum of 50 mbps download 10 mbps upload. Please consult with your internet provider or run a speed test here to confirm your internet connection meets these requirements.

Remote Work :

Yes

Employment Type :

Fulltime