The primary role of the Resolution Specialist is to resolve provider disputes for Fee Negotiation, Network, Multi-Service and Bill Review & Audit claims; including renegotiating claims if the need arises. Individuals who succeed in this role will demonstrate excellent customer service skills, which include strong verbal and written communication skills. This position will be responsible for metrics such as average time to resolve a dispute, average savings retention, frequency of dispute handling, and accurate documentation; all in an effort to best service our clients and providers. Other requirements involve the delivery of prompt, accurate, and cost-effective service for clients, and to meet or exceed company and client expectations for service. The individual will use problem-solving skills to resolve issues with diplomacy and accuracy.
- Research and resolution of provider and client billing inquiries including renegotiating claims as necessary to secure savings, while meeting or exceeding department KPI goals.
- Maintains tracking of all necessary information related to the research and resolution of assigned work.
- Works closely with internal staff, including Client Services, Network and Vendor Management, Out of Network Services and Bill Review & Audit for coordinate and promptly resolve issues
- Assists other department members in resolving complex claims or escalated provider issues.
- Communicates directly with clients to provide status updates and notification of resolved issues
- Maintain awareness of and ensure adherence to HIPAA and Zelis standards regarding privacy.
- Provides coverage and support for the Customer Care Team when needed
- Performs other related responsibilities as assigned.
- High School diploma required, Associate's degree preferred
- 1-2 years of medical claims experience
- 3+ years of experience within healthcare industry
- Solid understanding of PPO networks as well as understanding and ability to interpret Explanation of Benefits, Plan Documents, PPO and Complementary Network discounts
- Outstanding written and verbal skills
- Knowledge of MS Outlook, MS Work, MS Excel and Internet Explorer
- Exceptional prioritization and organizational skills
- Excellent customer service and telephone skills
As a leading payments company in healthcare, we guide, price, explain, and pay for care on behalf of insurers and their members. We’re Zelis in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all. We partner with more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, over 4 million providers, and 100 million members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.
Commitment to Diversity, Equity, Inclusion, and Belonging
At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day.
Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
We encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities.
We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email TalentAcquisition@zelis.com
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