Virginia Premier Health Plan Research & Resolution Specialist in Glen Allen, Virginia

About Us

Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.

By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.

At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.

If this sounds like you, read on!

Overview

The position is responsible for all research and resolution of claims inquiries and Claims Reconsiderations escalated by provider for all lines of business.

Responsibilities

  • Research and resolve claims issues that have been escalated by providers through Claims Reconsiderations and Claims Inquiries that are brought forth by Claims Customer Service, Network Development, and Provider Resolution Managers

  • Research and resolution may include coding/billing issues, systemic claims issues, electronic submissions, and refunds received

  • Coordinate claims resolutions with all appropriate departments in order to resolve issues

  • Process, adjust, and key claims accurately and timely following established guidelines for accuracy, quality, and productivity

  • Identify track and trend claims payment errors in order to determine root causes and actions needed to correct problems.

  • Identify trends from provider complaints regarding code edits and business decisions that impact claims payments

  • Other miscellaneous duties/activities as assigned

  • The ability to work overtime as needed

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • High School diploma required

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Strong communication skills (both verbal and written)

  • Exposure to health care call center environment

  • Ability to conduct research

  • Experience with IDX and QNXT Claim processing systems

  • Ability to work independently as well as in a team environment

  • Strong organizational skills

  • Strong Time Management skills

  • Knowledge of CPT-4, HCPCS coding and ICD10

  • Knowledge of CMS 1500 and UB04 claim forms

  • Ability to meet deadlines and work under pressure

WORK BACKGROUND/EXPERIENCE

  • Minimum 3 years claim processing experience, preferably with Medicare/Medicaid

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

Our mission is to inspire healthy living within the communities we serve!

Job ID 2018-4994

As an equal opportunity employer, Virginia Premier is committed to a diverse workforce. To ensure non-discrimination and affirmative action for individuals protected by Executive Order 11246, as amended, Section 503 of the Rehabilitation Act of 1973, as amended, the Vietnam Veterans’ Readjustment Act of 1974, as amended, and Title I of the Americans with Disabilities Act of 1990, as amended, Virginia Premier will consider applicants for employment without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. Applicants who require accommodation in the job application process may contact Recruitment at 804-819-5151 for assistance. It is the policy of Virginia Premier Health Plan, Inc., to comply with the requirements of the Drug-Free Workplace Act of 1988. It is a violation of our drug-free workplace policy to use, possess, sell, trade, and/or offer for sale alcohol, illegal drugs or intoxicants in our workplace. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. Virginia Premier participates in E-verify.