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Responsibilities

• Assist and educate 1199SEIU members and providers with out-of-network fees and out-of-pocket expenses related to contract benefits.
• Negotiate and resolve a large volume of complex, high-dollar balance billing inquiries, fees, and discounts with non-participating providers via telephone and written correspondence.
• Maintain ongoing communication with providers, members, attorneys, or collection agencies to resolve balance billing/fee negotiation inquiries.
• Proactively negotiate claims impacted by the No Surprises Act (NSA), focusing on resolving disputes with out-of-network providers to avoid escalation to Independent Dispute Resolution (IDR).
• Leverage communication and negotiation strategies to achieve mutually agreeable payment solutions for NSA claims.
• Assess claim details and potential outcomes to determine when negotiation is more beneficial than escalating to IDR, utilizing various benchmarks.
• Oversee and update internal channels to ensure access to accurate information regarding Balance Billing requirements.
• Utilize various databases to assess and compute reasonable rates, negotiating claim payments with providers, attorneys, and collection agencies on behalf of members.
• Assist in developing and maintaining reporting structures for NSA claims, tracking key metrics such as settlement rates, cases escalated to IDR, and overall compliance.
• Assist in generating and presenting detailed reports on NSA-related claim outcomes, including settlement rates, IDR escalations, and resolution timelines.
• Contribute to developing, maintaining, and monitoring tracking databases to enhance Balance Billing Department functions and improve workflow efficiency.
• Assist in training new and current staff on balance billing and fee negotiation procedures to meet department performance standards.
• Collaborate closely with the Manager of Balance Billing Fee Negotiation to track, report, and achieve departmental goals.
• Proactively identify and communicate any barriers to achieving departmental objectives to management.
• Support management in coordinating and executing Balance Billing Department workflow initiatives and projects.
• Assist in preparing and presenting daily, weekly, and monthly tracking reports to management, highlighting key trends and outcomes.
• Conduct research and provide recommendations for process improvements, enhancing the efficiency and effectiveness of operations.
• Perform special projects and other duties as assigned by management.

Requirements

• Associates degree or equivalent years of experience.
• Minimum three (3) years hospital and medical claims processing experience.
• Minimum two (2) years of negotiation experience required.
• Excellent knowledge of health claims, eligibility rules, and Coordination of Benefits (COB).
• Familiarity with the No Surprises Act (NSA): Comprehensive knowledge of NSA regulations, including experience navigating surprise billing protections, Independent Dispute Resolution (IDR) processes, and the Qualified Payment Amount (QPA).
• Excellent critical thinking, attention to detail, and problem-solving skills.
• Ability to work well independently and as a team player.
• Demonstrate analytical and organizational skills with the ability to multi-task and meet operational deadlines.
• Excellent math skills and the ability to translate mathematical information into concise reports.
• Ability to conduct various data comparison analyses.
• Working knowledge of macros, tables, forms, queries, and reports necessary.
• Proficiency in Microsoft Office (Word, Excel, Access, Outlook etc.).
• Ability to grasp and utilize new software systems.
• Ability to work well under pressure, maintain a professional manner and presentation.

Skills

• Negotiation
• Balance Billing
• No Surprises Act (NSA)
• Independent Dispute Resolution (IDR)
• Claims Processing
• Coordination of Benefits (COB)
• Microsoft Office Suite (Word, Excel, Access, Outlook)
• Data Analysis
• Reporting
• Problem-Solving
• Critical Thinking
• Attention to Detail
• Organizational Skills
• Multi-tasking

Experience Level

• Minimum 3 years hospital and medical claims processing experience
• Minimum 2 years negotiation experience

Education Level

• Associate's degree or equivalent experience