Claim Specialist - The Phia Group

Claim Specialist needed to combat rising healthcare costs and empower health plans! The Phia Group is a service-oriented consultant that assists health plans nationwide. We provide our clients with innovative cost-cutting solutions and innovative service offerings. We continue to enjoy growth thanks to our most valuable resource – our talented and committed team.

Until recently, surprise medical bills were a leading cause of financial distress and bankruptcy for American families. “Surprise” billing occurs when a patient presents to an out-of-network medical provider through no fault of their own – like in the case of an emergency – and the patient becomes responsible for amounts beyond what their insurance pays. Thankfully, beginning in 2022 with the implementation of the “No Surprises Act”, the legislature effectively banned surprise billing, instead prescribing a system of negotiation and arbitration that health plans and providers must follow to resolve billing disputes.

The Claim Specialist will be responsible for supporting the team on all aspects of the No Surprises Act, including reviewing medical claims, keeping track of strict deadlines, drafting settlement agreements, and preparing submissions for Independent Dispute Resolution, among many other tasks. The candidate will also be expected to support the team on balance billing and overpayment matters as needed. This position requires someone that is proactive, persuasive, persistent, respectful, and assertive. The candidate must be comfortable multi-tasking and possess strong communication skills, both oral and written. The Phia Group is growing quickly and so the candidate must be comfortable in a dynamic fast-paced environment.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Manage a daily running inventory of unpaid claims or claim disputes.
• Review and prioritize claims based on processing criteria, timelines, client demands, and service level standards.
• Contact facilities and providers to discuss charge adjustments and rationale.
• Contact facilities and explain benefits to resolve payment disputes.
• Draft correspondence pertaining to settlement and negotiation efforts for providers and other entities.
• Capture detailed notes on calls for future reference.
• As needed, handle member inquires in accordance to their medical plan.
• Work with The Phia Group’s legal department to ensure escalation of claims.
• Participate in on-going process improvement to develop efficiencies that streamline the claim settlement process.
• Ability to properly handle confidential information in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

Experience and Qualifications

• Preferred: Baccalaureate degree (BA/BS) from an accredited college or university.
• Preferred: Experience in a medical healthcare claims role, preferably involving negotiation, or experience at an insurance company, TPA, or hospital, preferably with emphasis in claims, fee schedules, or contracting.
• Computer literate, including Microsoft Office products.

Working Conditions / Physical Demands

Sitting at workstation for prolong periods of time. Extensive computer work. Workstation may be exposed to overhead fluorescent lighting and air conditioning. Fast paced work environment. Operates office equipment including personal computer, copiers, and fax machines.

This job description is not intended to be and should not be construed as an all-inclusive list of all the responsibilities, skills or working conditions associated with the position. While it is intended to accurately reflect the position activities and requirements, the company reserves the right to modify, add or remove duties and assign other duties as necessary.

External and internal applicants, as well as position incumbents who become disabled as defined under the Americans with Disabilities Act, must be able to perform the essential job functions (as listed here) either unaided or with the assistance of a reasonable accommodation to be determined by management on a case by case basis.