Health Payer Escalated Contract and Billing Specialist

Overview

Key responsibilities include ability to interpret complex health insurance contracts, understand billing processes, and effectively communicate and resolve escalated payment issues with insurance carriers working within the billing and contracting teams.

Responsibilities

• Contract & Benefit Interpretation: Review and apply health insurance contracts to billable services, benefit policy terms, and coverage limitations to determine eligibility and payment eligibility for claims per contract expectations according to benefit parameters.
• Demonstrate billing process expertise to identify and address escalated payment issues as a result of internal billing discrepancies.
• Investigate and resolve escalated payment disputes, including denied, underpaid, or delayed claims, by coordinating with health insurance contract stakeholders as well as internal stakeholders.
• Build data-driven cases to support, justify, and advocate for escalated claims payments.
• Able to review claims submission for internal errors creating escalated payment issues and communicating those details

Qualifications

• Bachelor’s degree in related field preferred
• Experience or strong understanding in contracting & contract management
• Experience in medical or insurance billing with a track record of resolving escalated payment issues.
• Proficiency in billing software, EHR systems, and claims submission platforms.
• Experience of or strong understanding of ICD-10, CPT, modifiers, and insurance payment terms.
• Experience with MPPR/Sequestration, coinsurance and Deductibles
• Coding Certification a plus
• Excellent time management, prioritization and organizational skills
• Experience in Outlook, Word, and PowerPoint desired
• Detail-oriented with strong organizational and problem-solving abilities
• Self-motivated and results oriented
• Proficiency in Microsoft Office applications, including Excel, Word and PowerPoint
• Excellent verbal and written communication and presentation skills
• Mininmal travel