Claims Negotiator I

POSITION SUMMARY Negotiate out-of-network claim payments with providers on behalf of group health plans. Such negotiations will be based on 1) various types of cost data, including “reasonable and customary” benefit levels and Medicare pricing, and 2) billing irregularities. ESSENTIAL FUNCTIONS

• Independently review and analyze health care claims for: 1) reasonableness of cost; 2) medically unnecessary treatment by physicians and hospitals; and 3) fraud.
• Determine whether a health plan provides benefits in connection with the claim submitted and the level of benefits to be paid to the provider.
• Contact providers to negotiate discounts.
• Reprice claims to the applicable Medicare rate.
• Log negotiated claims into the Access database and create weekly summary reports.
• Review and understand the terms and conditions of each client’s customized plans.
• Understand and comply with all applicable privacy and security laws, including but not limited to HIPAA, and any regulations promulgated thereto.
• Request, review and analyze any physician notes, hospital records or police reports.
• Consult with other entities who can offer additional evaluation of a claim.
• Process claims in the QicLink System.
• Review, analyze and add applicable notes to the QicLink System.
• Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com.
• Review billed procedure and diagnosis codes on claims for billing irregularities.
• Analyze claims for billing inconsistencies.
• Review and analyze specific procedure and diagnosis codes for medical necessity.
• Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
• Review Suspended Claim Reports and follow up on open issues.
• Assist and support other team members as needed and when requested.
• Attend continuing education classes as required, including but not limited to HIPAA training.
• Performs other related duties as assigned

EDUCATION

• Bachelor’s degree or equivalent work experience required.

EXPERIENCE AND SKILLS

• A minimum of 5 years of medical claims analysis experience required.
• Must have strong analytical skills.
• Must have knowledge of computer systems and CPT and ICD-9 coding terminology.

POSITION COMPETENCIES

• Job Knowledge
• Time Management
• Accountability
• Communication
• Initiative
• Customer Focus

PHYSICAL DEMANDS This is a standard desk role – long periods of sitting and working on a computer are required. WORK ENVIRONMENT Remote Here at Allied, we believe that great talent can thrive from anywhere. Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for success. To support a smooth and efficient remote work experience, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Reliable internet service is essential for staying connected and productive. The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate. Compensation is not limited to base salary. Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life & Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend. Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time. All applicants acknowledge that by applying to the position you understand that the specific pay range is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process. It is at the Company's discretion to determine what pay is provided to a candidate within the range associated with the role. Protect Yourself from Hiring Scams Important Notice About Our Hiring Process To keep your experience safe and transparent, please note:

• All interviews are conducted via video.
• No job offer will ever be made without a video interview with Human Resources and/or the Hiring Manager.

If someone contacts you claiming to represent us and offers a position without a video interview, it is not legitimate. We never ask for payment or personal financial information during the hiring process. For your security, please verify all job opportunities through our official careers page: Current Career Opportunities at Allied Benefit Systems Your security matters to us—thank you for helping us maintain a fair and trustworthy process! Apply tot his job Apply To this Job