Claims Resolution Specialist

MPF Federal is seeking a Claims Resolution Specialist for a short-term contract of roughly 3 months, you will be responsible for meticulously investigating, recovering, and resolving various types of claims within the parameters of our contractual obligations. This role will involve educating and informing members and providers about program coverage and limitations, employing critical thinking, research, and problem-solving skills to navigate the complexities of members' health benefits and claims. You'll need to maintain detailed records in our internal database while ensuring compliance with program guidelines.

Primary Responsibilities:

• Manage assigned claims inquiries, providing assessment, education, and coordination for members and healthcare providers, while maintaining accurate records.
• Cultivate positive relationships with members, providers, and our claims contractor to facilitate effective communication and resolution.
• Demonstrate expertise in your role, including the ability to request and manage medical records to assess program coverage.
• Complete system-generated tasks, document results, and prepare comprehensive reviews and summaries for claim appeals.
• Serve as a point of contact for internal departments regarding member claims and collaborate on solutions to resolve program issues.
• Ensure claims are resolved throughout the entire process, proactively identifying solutions to non-standard requests and inquiries.
• Handle emotionally charged phone calls and communicate complex program criteria effectively in both oral and written formats.
• Validate claim coverage in accordance with program guidelines and meet established objectives and metrics.
• Fulfill activities and reporting requirements as outlined in the fraud, waste, and abuse plan.
• Perform periodic balancing and reporting activities, as well as research and verification of identified claims.

Required Qualifications:

• Minimum of three years of claims processing or similar experience.
• Proficiency in Microsoft Office Suite and ability to work independently or as part of a team.
• Excellent verbal and written communication skills, including strong telephone etiquette and interpersonal skills.
• Ability to adapt to varying duties and maintain composure under pressure.
• Demonstrated critical thinking and decision-making skills, with attention to detail and goal orientation.

Preferred Qualifications:

• Associate’s Degree in Business Administration or related field.
• Certification in Medical Coding or Registered Health Information Technician (RHIT) preferred.
• Experience in a medical call center or corporate healthcare setting.
• Completion of Certified Medical Reimbursement Specialist (CMRS) exam or equivalent certification.
• National Career Readiness Certificate and dental claims processing experience are a plus.

MPF Federal is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or on the basis of disability.