Now Hiring - Provider Resources, Inc - Sr. Health Insurance Specialist JD/Arbiter 4.5.2024 in El Paso, TX

Position Description: Sr. Health Insurance Specialist JD/Arbiter

Under the direction of the Independent Dispute Resolution Entity (IDRE) Stakeholder Engagement Subject Matter Expert or his/her designee, the Sr. Health Insurance Specialist JD/Arbiter (HIA) applies critical thinking skills, IDRE program policies and regulatory guidance to analyze and adjudicate payment determination disputes between nonparticipating providers, nonparticipating emergency facilities or nonparticipating providers of air ambulance services and a group health plan. Health Insurance Arbiter reviews all documentation received from the involved parties in regard to their proposed payment amount and renders an independent determination, selecting one of the two proposed offers, based upon the credible facts presented. The Health Insurance Arbiter JD specializes in air ambulance disputes and settlements as well as researching complicated cases giving feedback to Senior Management. The position may require drafting of guidance for the program and stakeholder communications as a result of changing regulations. In addition to review, the Health Insurance Arbiter completes all case related documentation and sends appropriate email notification as per the established workflow. They are also responsible for timely and accurate case specific data entry into the government portal.

Responsibilities:

• Understand and represent PRI? mission, vision, and values to all internal and external customers
• Interact with government and private sector clients, partners, and PRI? staff in a professional and accountable manner, and as a representative of PRI management
• Interact with project team members in order to successfully fulfill contract obligations with the highest quality and in a timely manner meeting PRITM?s ISO requirements
• Instills integrity throughout the organization via active participation in ISO requirements including but not limited to timely submission of Corrective Action Plans for all matters in which either PRITM standards and/or corporate contract standards have not been met. Communicates outcomes to team members to ensure a positive, open, environment which mitigates risk and achieves a culture of Continuous Quality Improvement
• Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the clien
• Proactively manages and coordinates activities to ensure timeliness of deliverables to exceed contractual obligations
• Contributes to business development efforts for new sales and marketing to promote the business through professional communications, sound decisions and by exceeding all contract timeframes and deliverable requirements,
• Utilize project resources for research and reference verification
• Flexible with assignments to meet contract performance metrics
• Participate in interdisciplinary collaboration with PRITM staff, recognized teaming partners, and/or subcontractors
• Demonstrated skill and experience in the submission of timely, accurate deliverables
• Demonstrated experience and skills in excellent customer service
• Proven skill and experience in excellent oral and written communication spanning executives to the general public
• Experience in analyzing, examining, adjudicating and resolving medical claims under the No Surprise Act or other similar federal law.
• Performs independent dispute resolution review and payment adjudication activities as needed
• Perform other duties as request.