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Disputes Resolution Specialist

Company: Prime Health Services, Inc.
Location: Franklin
Posted on: May 13, 2022

Job Description:

The Disputes Resolution Specialist acts as a liaison between the provider, the client, and affiliate network partners to quickly and accurately resolve claim repricing disputes. This position researches provider participation and determines the correct repricing of disputed claims while maintaining pre-existing relationships between Prime Health, clients, and providers. The Disputes Resolution Specialist will serve as the first level liaison between the provider and Prime Health Services clients to resolve PPO disputes. This position reports to the VP of Patient Advocacy.
Essential Job Functions

Reviews all available claim dispute information including EOB, claim form, and provider appeals.
Researches Prime Health Services/provider contract and other documents to determine an accurate resolution.
Communicates resolution with clients, providers, and affiliate networks in a professional and timely manner.
Logs claim disputes accurately based on the submitted EOB and claim form.
Answers provider inquiries over the phone and via email.
Meets monthly dispute resolution goals as determined by the Manager of Disputes Resolution.
Discusses difficult resolutions in a calm and professional tone.
Maintains integrity by determining the most accurate resolution for disputed claims.
Works with other Disputes Resolution Specialists and Manager of Disputes Resolution on special projects when necessary.
Handles Workers Compensation, Group Health, and/or Auto PPO disputes.
Follows the department training guide to ensure correct steps are followed to complete the resolution process.

High school diploma or GED and 1 year of clerical or customer service experience
An Associate's Degree in Business or related field of study from an accredited college or university is preferred. Prior direct experience is preferred

Competencies

Proficient in Microsoft Office Suite, including Office, Excel, and Outlook
Friendly, professional demeanor
Excellent written and oral communication skills
Excellent investigative and problem-solving abilities
Exceptional organization and time management skills - ability to handle a high volume of accounts
Ability to work effectively and collaboratively in a team environment
Strong attention to detail and accuracy
Ability to handle stressful situations with a calm demeanor
Experience working in a deadline driven environment

Who We Are
Prime Health Services is a national medical cost containment company offering a PPO network to the workers' compensation, group health, corrections, and auto liability markets. Our preferred provider network has been expanding since 2001 and now has over 800,000 medical providers and health care facilities nationwide with over 900,000 locations. The Prime Health Services PPO Network is available to insurance carriers, third-party administrators (TPAs), self-insured employers, governmental entities, corporations, and associations.
We look for candidates who build a culture of teamwork and positive results. To be successful at Prime, you need to be forward-thinking, have an innovative spirit, be empowered to do your job well, act collaboratively, and be reliable. We're a company on the move and strive for excellence in everything we do!
If this sounds like you, please submit your application today or pass this along to anyone who is searching for their next role with a growing company.

PM21PI177162241

Keywords: Prime Health Services, Inc., Franklin , Disputes Resolution Specialist, Other , Franklin, Tennessee

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