Claim Lead Representative, Payer Solutions – Evernorth- Remote

** Any Work at Home Location is Acceptable for This Position **

Responsibilities:

• Researches, analyzes and calculates claims in accordance with provider contracts
• Works with internal matrix partners to resolve pended claims/tickets issues
• Utilizes our SRS system to route work items to matrix partners and external retailer claim administration staff
• Follow audit protocols and workflows to ensure quality goals.
• Special pricing projects as requested by retailers
• Partners with matrix organizations to ensure that appropriate action is taken to identify and implement high potential process improvements
• Supports and drives process improvement to further enhance claim accuracy outcomes
• Engagement, partnership with supervisor, claim processing team, and other internal and external partners
• Position requires excellent interpersonal skills; ability to understand and interpret policy provisions, and to present report analysis and meaningful findings in a clear, concise way.
• Pricing identification of errors and management of resolution with provider contracting/maintenance internal teams.
• Identifies steps necessary to process a varying complexity of contracts for pricing accuracy

Qualifications:

• 1 year of Payer Solutions claim processing technical knowledge and application
• Customer Service Driven; ability to meet and exceed the internal partner and external customer expectations
• Take accountability in critical thinking and decision-making outcomes
• Problem solving skills; utilization of technical skills and resources to ensure accuracy of final claim resolution
• Strong communication skills, both verbal and written
• Ability to teach, educate, coach others through a variety of claim complexities
• Process improvement skills; ability to assess trends, processes, and barriers to drive positive outcomes for claim resolutions
• Fluent understanding and application of key tools and resources for claim processing; C-Kit 2.0, Calculators, CPF/PWB, SANP, Facets, etc.
• Comfortable working with others in multiple locations; office and work at home
• Basic knowledge with Word, Excel, PowerPoint, WebEx and Outlook preferred

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an hourly rate of 22 – 33 USD / hourly, depending on relevant factors, including experience and geographic location.