Where PrecisionMeets Purpose.

Job purpose

Ensuring timely and accurate claim follow-up, denial resolution, and appeal submission while monitoring BPO agents performance through daily guidance, quality reviews, and training. Ensure claim activity meets payer requirements and contributes to overall department efficiency.

Duties & responsibilities

1. 01If needed, maximize productivity while performing timely claim follow-up via phone and portals, resolving denials, statusing claims, and drafting appeals.
2. 02Monitor and support BPO agents handling claim statusing and denial resolution, providing daily guidance, productivity monitoring, and alignment with departmental standards.
3. 03Handles high-level escalations for BPO agents.
4. 04Audit BPO claim work for accuracy, completeness, and compliance, identifying training gaps or errors for corrective action.
5. 05Provide training for new hires and lead refresher sessions as needed, supporting BPO development through material and coaching.
6. 06Track BPO KPIs and report underperformance to the Director and Lead to assist in action plans.
7. 07Ensure documentation of all claim-related actions in Jira and CollaborateMD, including updates, payer responses, reimbursement, and escalation notes.
8. 08Maintain up-to-date knowledge of payer requirements, authorization rules, and communication standards to ensure accurate claims processing.
9. 09Engage in team and interdepartmental meetings to troubleshoot issues, identify denial trends, and recommend process improvements.
10. 10Communicate department needs and performance concerns to the Director and lead while supporting accountability and development.
11. 11Participate in the department's L10 meetings, identify and bring issues, and develop and execute To-Dos and quarterly rocks to drive alignment and improvements toward Cipher VTO.
12. 12Performs other related duties as assigned.

Job purpose

This role makes sure agents complete their department work on time and with accuracy. It also collects, organizes, and analyzes data so payer trends and claim adjudication outcomes are easier to predict.

Duties & responsibilities

1. 01If needed, maximize productivity while performing timely claim follow-up, and contact negotiators each day to confirm they received a response or to clarify a counterargument.
2. 02Own follow-up, research, and coordination for proposed negotiations and claim denials across the portal, scanned documents, faxes, and email, and keep those records easy to find.
3. 03Document and update payment information in CollaborateMD, and organize the work schedule around Jira due dates.
4. 04Use CMD, the Anthem Claims Routing tool, Kipu, the Reimbursement Tool, and Availity to compare past payment rates for similar members or facilities.
5. 05Handle high-level escalations for BPO agents, and send complex claims and challenges to department leadership as they come in.
6. 06Watch net gain, net loss, and the KPIs for assigned work, and use those results to set priorities and spot improvements.
7. 07Support BPO agents on daily negotiations and on weekly and monthly TPP submissions, and audit claim work for accuracy, completeness, compliance, and training gaps.
8. 08Track BPO KPIs and report underperformance to department leadership so they can build an action plan.
9. 09Participate in the department's L10 meetings, identify and bring issues, and develop and execute quarterly rocks to drive alignment and improvements toward Cipher VTO.
10. 10Perform other related duties as assigned.