Claims Escalation Rep

We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only).

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

As part of the claims escalation team, provides training, resolution and daily direction to the Claim Customer Service Representatives. Supports team by researching claims data, claim system, and authorizations to resolve provider claims questions. Interacts with outside entities and internal departments to resolve claims inquiries. Utilizes multiple software applications, applies business rules, and knowledge of provider or authorizations to resolve provider claims questions. Works under timelines while meeting accuracy and production goals.

Education & Experience

Required:

• High School diploma or G.E.D.
• One year experience working in a call center
• Proficient with Microsoft Outlook, Word and Excel
• Strong Knowledge of medical terminology
• 2 years claims resolution, billing experience or demonstrated success as a TriWest Claims Customer Service Representative
• Strong written and verbal communication skills

Preferred:

• Associates degree in healthcare or related field

Key Responsibilities

• Reviews, analyzes and directs resolution of complex claims issues.
• Interfaces with Claims and CCOPs leaders, CSRs, other internal departments, VA and vendors.
• Serves as a Subject Matter Expert to Claims Customer Service Representatives and other internal departments.
• Investigates recurring problems, identifying process improvements and reporting findings to leadership.
• Tracks daily questions and resolution trends.
• Documents all communications involving staff, Veteran, and provider contacts.
• Reviews large amounts of complex information from multiple sources, including validating appropriate data on claim.
• Collaborates with Claims sub-contractor to build or update authorization and provider records.
• Participates in training documentation creation and updates.
• Manages multiple task lists in accordance within directed timelines.

• Maintains updated knowledge of software applications, Claims trends, and Claim CSRs' procedures and processes.
• Complies with HIPAA regulations to protect privacy of health information.
• Consistently meets department productivity and performance metrics.
• Manages and prioritizes daily workflow queues to ensure timeliness standards are met.
• Identifies and reports any potential quality or fraud issues to management.
• Practices professional and concise communication in writing and by phone.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Competencies

Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback.

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; Adapt to different styles; Listen critically; Collaborate.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.

Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; Commitment to task to produce outcomes without direction and to find necessary resources.

Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.

High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.

Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-oriented.

Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; Has a realistic understanding of relevant issues.

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.

Technical Skills: Knowledge of CCN policies, processes, and procedures, knowledge of call management methodology.

Working Conditions

Working Conditions:

• Ability to cover any work shift with no travel
• Works within a standard office environment
• Extensive computer work with prolonged sitting and wearing of headset
• VA-approved security clearance may be required

Company Overview

Taking Care of Our Nation's Heroes.

It's Who We Are. It's What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We're On a Mission to Serve®!

Our job is to make sure that America's heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we've proudly been on that important mission since 1996.

Benefits

We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Generous paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

*Annual base salary for Colorado, Hawaii, Washington D.C. and Washington State residents: $47,654.21- $50,301.66 depending on experience*

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.