Senior Provider Escalations Analyst

This is a fully remote position, open to applicants in Florida, +2 more states.

📋 Description

• Address impacted multi-claim issues by analyzing claim impact reports and initiating necessary sweeps.

• Explore claim payment or denial results for high-profile provider escalations via PIR, regulatory, legal, or presidential escalation channels.

• Modify complex claims for designated lines of business and markets.

• Adjust voids, rekey, and reopen claims online in accordance with established guidelines.

• Interpret benefits, policies, procedures, provider contracts, and claims adjudication processes.

• Examine systems and processes that span multiple operational areas and claim systems.

• Propose solutions for contract disputes, non-routine claim challenges, billing inquiries, and other operational practices.

• Identify obstacles and promote process improvement initiatives.

• Manage communication regarding medical policy, reimbursement, and provider utilization trends.

• Act as a liaison and subject matter expert for both internal and external business partners.

• Guide and train provider escalation analysts.

• Oversee UAT testing and other project assignments.

• Collaborate with internal and external business partners to uncover root causes and resolve issues.

⛳️ Requirements

• High school diploma or GED required.

• At least 8 years of experience in claims research and/or issue resolution or analysis of reimbursement methodologies within the healthcare sector.

• Experience in both internal and external customer service.

• Any combination of education and experience that provides a comparable background.

• Experience in independent dispute resolution is highly desirable.

🏝️ Benefits

• Merit increases.

• Paid holidays.

• Paid Time Off.

• Incentive bonus programs.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• Short-term disability benefits.

• Long-term disability benefits.

• 401(k) with matching contributions.

• Stock purchase plan.

• Life insurance.

• Wellness programs.

• Financial education resources.

• Virtual full-time work with mandatory in-person training sessions.

• Flexible work-life integration and autonomy.