Resolution Specialist (Claims)

Job Description

Responsibilities

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 3, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 4. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.

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Job Summary:

The Resolution Specialist is responsible for handling all aspects of enrollment for all lines of business. This position works with the Enrollment Supervisor to resolve escalated enrollment issues and is expected to gain and maintain proficiency with all enrollment systems. Prepares, processes, uploads and maintains new and existing member information in the core database. Responds to employer sponsor or broker eligibility and enrollment questions, including verifying enrollment status, ID card requests, demographic changes, as well as escalated issues. Works closely with IT/EDI staff, system programmers, as well as new and existing clients to ensure all components of electronic enrollment are programmed and loaded appropriately. Performs reconciliation and audits of membership.

About Universal Health Services:

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.

Qualifications

Qualifications and Requirements:

• High school diploma or equivalent. Associates degree preferred.
• Minimum 3 years related experience health plan experience, in claims or customer service,
• 3-5 years’ experience with Medicare Advantage, HMO, PPO, and self-funded products preferred
• Excellent verbal and written communication skills as well as public speaking and training abilities and experience.
• Previous experience reviewing and analyzing statistical data to identify trends as well as potential problems/opportunities for improved service quality.
• Knowledge of State and Federal regulations as they pertain to the health insurance industry.
• 1 to 3 years’ experience. Basic knowledge of Medicare regulations, experience in Managed Care Enrollment (MA, MAPD and PDP), Other Skills: Must possess previous experience processing Medicare Advantage enrollment applications and generating letters
• Ability to effectively communicate in English, both verbally and in writing.
• Previous experience reviewing and analyzing statistical data to identify trends as well as potential problems/opportunities for improved service quality.
• Experience working with CMS contracted vendors and systems, such as Retroactive Processing Contractor (RPC), Wipro, MARx, etc. is preferred.
• Experience in computer operations including troubleshooting experience and preferably electronic data interchange experience.
• Ability to analyze statistical data and recognize problems or potential problems and take appropriate steps to resolve the problem.
• Self-starter with the ability to recognize priorities and manage workload accordingly.