Reimbursement and Complex Claims Analyst

🕒 October 6

🐎 Kentucky – Remote

🐎 Kentucky – Remote

💵 $55k - $65k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Claims Specialist

👻 Ghost score 0%

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The Phia Group, LLC

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2000

💼 Consulting

🏥 Healthcare

🛡️ Insurance

💰 Private Equity Round on 2018-09

Consulting • Healthcare • Insurance

The Phia Group, LLC is a dedicated provider of healthcare cost containment solutions, focusing on empowering self-funded health plans to maximize benefits and minimize costs. Through a comprehensive suite of services, including subrogation and recovery, claims negotiation, and cost transparency initiatives, The Phia Group aims to help employers and families navigate the complexities of healthcare with advocacy and expertise. Their commitment to improving healthcare accessibility and affordability sets them apart in the industry.

📋 Description

• Negotiate agreements with facilities and providers to establish appropriate reimbursement terms before services are rendered or claims are submitted. • Manage a daily inventory of pre-service requests, pre-claim matters, unpaid claims, and claim disputes. • Review and prioritize matters based on processing criteria, timelines, client demands, financial exposure, and service level standards. • Contact facilities and providers regarding reimbursement arrangements, charge adjustments, payment terms, and supporting rationale. • Draft correspondence and agreements for negotiation and settlement efforts. • Capture detailed notes on calls and negotiations for internal teams, external clients, providers, and collection offices. • Handle complex and high-dollar claims under sensitive timelines and escalate client issues or concerns involving high-touch negotiations. • Work with the Provider Relations escalation team and legal department on complicated matters. • Support daily repricing, research, claim review, system updates, and operational tasks. • Maintain the centralized data repository, including fee schedules, crosswalk tables, and other data sources essential to repricing operations. • Participate in client configuration maintenance and new client implementations. • Participate in projects focused on coding, benchmarking, reimbursement, and clinical considerations. • Maintain and update standard operating procedures under Provider Relations management. • Properly handle confidential information in accordance with HIPAA.

🎯 Requirements

• Preferred: Baccalaureate degree (BA/BS) from an accredited college or university. • Preferred: AAPC Certified Professional Coder (CPC) credential or comparable coding and reimbursement expertise. • Experience in a medical healthcare claims role, preferably involving negotiation, reimbursement, repricing, or complex claims, or experience at an insurance company, third-party administrator, or hospital with emphasis in claims, fee schedules, or contracting. • Knowledge of healthcare reimbursement methodologies, fee schedules, medical coding, and provider contracting concepts. • Strong oral and written communication, negotiation, organization, and problem-solving skills. • Strong data literacy skills with the ability to triage, organize, and interpret multiple data sources. • Computer literate, including Microsoft Office products. • Ability to perform essential job functions unaided or with reasonable accommodation. • Ability to handle confidential information in accordance with HIPAA. • Ability to sit at a workstation for prolonged periods and perform extensive computer work.

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