Analyzes and validates claims payments against payer contract terms to ensure payer compliance. This role requires detailed knowledge of contractual agreements, contract interpretation, reimbursement methodologies, and configuration. The specialist identifies payer-specific trends and reports significant or recurring issues to the next-level specialist and supervisor.
Key responsibilities
- Work payment variance queues to identify payer-specific trends and recurring issues
- Review validation reports and recommend configuration changes
- Maintain knowledge of complex hospital-specific reimbursement methodologies
- Serve as a resource for hospital follow-up and denial teams on reimbursement questions
- Investigate and research contract and fee schedule configuration issues
- Report payer compliance issues to leadership
- Perform other related tasks and projects as assigned
One to two years of experience in a hospital or physician medical claims processing, insurance billing, or insurance collections environment.
Required knowledge and skills
- Knowledge of third-party reimbursement and contracts
- Understanding of the full insurance claim lifecycle
- Ability to interpret payer 835 data
- Strong analytical, problem-solving, and investigative skills
- Strong interpersonal skills and ability to work across departments in the revenue cycle
- Organizational skills and ability to analyze reports and interpret reimbursement models
- High attention to detail
Presbyterian offers a comprehensive benefits package for benefits-eligible employees, including:
- Medical insurance
- Dental insurance
- Vision insurance
- Short-term disability
- Long-term disability
- Group term life insurance
- Optional voluntary benefits
Additional wellness benefits may include employee wellness rewards, gift cards, wellness challenges, webinars, and preventive screening opportunities.
Location
New Mexico, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
Yes
Posted
2 weeks ago