CNSI is empowering the delivery of public sector healthcare in claims and encounter processing platforms, provider support solutions, and promoting consumer engagement and interoperability. Our technology-enabled products and solutions connect consumers, payers, and providers to improve health outcomes for one in five Americans.

Claims Resolution 2 will assist with bill-specific research to resolve outstanding issues and provide guidance in a variety of duties according to Wyoming Department of Health. This position is responsible for accurate and timely research of all claim dispute types, timely processing of adjustments, and acts as a liaison between members, providers, agency, and internal claims department. Determine if a recalculation is warranted and modification to the payment amount is necessary. This position requires demonstration of leadership, collaboration, achieving results, developing and mentoring others, and strong attendance. The right candidate will show teamwork and help support leadership with policies while building and maintaining morale within the team. This position is located in Cheyenne, Wyoming or Tallahassee, Florida.

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Job Responsibilities:

• Independently resolve suspended claims using the resolution screens in accordance with operational procedures and process recoupments
• Determine when to use a "Forcible" disposition to override the edit and process the claim based on operational claims adjudication procedure
• Review and analyze claims and follow up on the status of claims and reimbursement
• Identify areas for provider education to promote provider claims correction on their first response and communicate these to management and Field Representatives
• Eliminate the back and forth with the Provider when correcting a claim
• Interpret and apply policy and reimbursement rules to support provider inquiries
• Ensure accuracy and consistency of claims processing
• Fix errors or inconsistencies as they are identified and notify staff member(s), when applicable, and re-train or corrective action as required
• Train on operational procedures and review operational procedures and standard management practice
• Independently research and resolve medical bill data, making necessary corrections of information by comparing data with source documents to identify root causes
• Request additional information needed to complete the adjudication of bills
• Research and review submitted bills (paper or electronic) requesting adjustment consideration, and process according to Wyoming Department of Health policies and procedures
• Make the appropriate bill adjustment into the claims system according to contractual requirements and timelines
• You will possess unwavering commitment to customer service and operational excellence
• Perform manual pricing and audit checks to ensure compliance with Wyoming policies and rules
• Review and process suspended claims and submitted documentation
• Facilitate manual entry of claims into the system
• Research and electronically track suspended claims
• Provide sufficient detail on claims denial reasons
• Implement workflow processes and capabilities for work queues with the ability to route workstreams between CNSI and the state
• Assist the state in simplifying business rules and policies
• Approve or deny requests for transportation authorization from providers, verify member transportation claims, and process approved claims
• Perform manual reviews on claims, documents, and attachments
• Release individual claims for providers on review
• Independently re-submit claims with applicable corrections
• Independently address discrepancies in charges, payments, adjustments, and demographic information
• Available to work from 7:00 AM to 6:00 PM Mountain Time on all State business days, Monday through Friday (excluding Wyoming State holidays)

Required Experience/Skills Required:

• You have a high school diploma or GED with at least 2+ years of experience conducting research to resolve issues within the healthcare field
• Expert knowledge of claims pricing methodologies such as DRG, manual pricing, and fee for service experience
• Have knowledge of medical bill/claim forms, ICD-9/10CM coding
• Outstanding customer satisfaction skills
• Must have the ability to be firm but professional with contacts while performing tasks
• Knowledge of Medicare, Medicaid and claims review and analysis
• Excellent oral and written communication skills
• Excellent organization and time management skills; and ability to establish priorities effectively
• Self-directed and capable of working without direct supervision

Preferred Experience/Skills:

• 
  Knowledge of mass adjustment processing and Special Batch handling
• Demonstrated knowledge of third-party billing procedures

CNSI is an equal-opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, marital status, genetic status, family responsibilities, protected veteran status, or any other status protected by applicable federal, state, or local law. We are proud of our diversity and encourage all qualified applicants to apply.