Claims Resolution Representative

Aug 21 2017
TriWest Healthcare Alliance |Honolulu|Full Time
Category: Healthcare
Job Description


Ensures accurate, timely maintenance, and synchronization of critical provider and or authorization data within provider/authorization databases and Facets.  Researches and resolves Veterans’ claims customer service inquiries. Accesses and utilizes multiple software applications, applies business rules and knowledge of provider and or authorization processes.  Communicates with internal and external customers by phone and email to clarify data and follow up on issues. Works under timelines while meeting accuracy and production targets.


Government Reporting






Education & Experience




•         High School Diploma or GED
•         2+ years in customer service, dispute resolution, provider data or similar experience in health care industry
•         Experience in a fast-paced production environment
Experience working with computer databases or information management systems
•         Experience with Microsoft Word, Excel and Outlook




•         Experience in claims or provider services
          Experience in in billing or collections


Key Responsibilities


Key Responsibilities


•         Investigates and analyzes claim, authorization, and provider data errors; summarizes and identifies resolutions
Responds via phone to Veterans and Providers on claims customer service inquiries
•         Collaborates with various team members to execute resolutions
•         Manages and prioritizes daily workflow queues to ensure timeliness standards are met
•         Reviews large amounts of complex information from multiple sources
•         Validates all appropriate data is supplied with health care claim
•         Reviews provider and/or authorization data to ensure accuracy
•         Contacts providers, requesting data updates or missing documentation for claims payments
•         Researchs and resolves claims disputes related to Other Health Insurance
Collaborates with Claims sub-contractor to build or update authorization and provider records in Facets
•         Certifies new providers to ensure licensure and credentials are valid
•         Identifies and reports any potential quality or fraud issues to management
•         Manages follow-up of all correction requests to completion
•         Practices professional and concise communication in writing and by phone
•         Performs other duties as assigned
•         Regular and reliable attendance is required




Technical Skills


Proficient with key databases, including Visual Cactus, CareRadius, and Facets.  Working knowledge of VA policies.  Current knowledge of claims, reimbursement methodology, medical coding; health care or managed  care experience


Team-Building / Team Player


Influence the actions and opinions of others in a positive direction and build group commitment.


Organizational Skills


Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-oriented.


Information Management


Ability to manage large amounts of complex information easily, communicate it clearly, and draw sound conclusions


High Intensity Environment


Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.


Coping / Flexibility


Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.


Computer Literacy


Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.


Communication / People Skills


Ability to influence or persuade others under positive or negative circumstances; Adapt to different styles; Listen critically; Collaborate.


Commitment to Task


Ability to conform to established policies and procedures; exhibit high motivation.


Working Conditions


Working Conditions


o        Favorable working conditions in a climate controlled office space; must be available to cover any work shift; works within an office environment with minimal travel required; level II IT security clearance.
o        Extensive computer work with prolonged sitting