Claims, Audit and Recovery
Provider Claims Research Representative
Louisville , KY, United States

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely--62% in year-over-year revenue growth through 2015. Are we recognized? Definitely. We’re 12th on Forbes’ list of America’s Most Promising Companies for 2015, one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

What You’ll Be Doing:

This position is responsible for researching and analyzing projects or correspondence, as well as giving recommendations to correct problems and identify error trends to ensure that department, contract and regulatory requirements are met. 

  • Functions as technical specialist for claims management operations. Analyzes complex operational problems, and provides technical solutions. Identifies and recommends areas where changes to existing processes and procedures can result in process and/or cost savings. Backup to customer service representatives via telephone and assists other claims examiners on claims backlog.
  • Resolves customer inquiries regarding coverage or potential changes to existing coverage; determines policy application; and, if necessary, directs customer issues to other units for resolution. Determines when additional information regarding other coverage, medical reports and investigations are required and initiate action to obtain required information.
  • Responds to and resolves provider and health plan claim inquiries.
  • Inputs claims into the system for appropriate tracking and processing. Documents files, as appropriate, to support payment decision. Identifies program gaps and assists with development of corrective action plans
  • Maintains a current working knowledge of processing rules, contractual guidelines, plan policies and operational procedures to effectively provide technical expertise.
  • Resolves and provides direction on complex cases utilizing strong investigative and research skills. 
  • Analyzes error reports and trends providing explanations and feedback to staff and management. 
  • Identifies key issues with projects and offers solutions.
  • Maintains a balance of productivity, quality and timeliness of job accountabilities. 
  • Identifies and defines problems and opportunities within work area and attempts to resolve through appropriate channels.
  • Provides technical and peer in-service training. 
  • Conducts cross training and act as mentor to staff as required. Serves as a subject matter expert as needed.
  • Perform other duties and projects as assigned.
Key Competencies/Success Factors:
  • Lives the values: Integrity, Community, Collaboration and Stewardship, as defined in the performance appraisal.
  • Demonstrated proficiency in the application of medical terminology, procedures and diagnostic codes.
  • Proficient experience using Outlook, Word, Excel and PowerPoint in a Windows operating system. 
  • Demonstrated knowledge of direct on-line processing.
  • Knowledge of claims handling procedures, legal concepts and financial concepts.
  • Ability to identify, analyze, and resolve complex issues quickly and efficiently and make sound decisions.
  • Ability to multi-task and prioritize work.
  • Ability to navigate through multi system applications.
  • Ability to comprehend and follow established office routines, policies and procedures.
  • Ability to effectively, accurately and effectively process high volume of transactions.
  • Professional conduct with customers.
  • Effective oral and written communication skills.
ADA Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Stationary position: Must be able to remain in stationary position 75% of the time. 
  • Use of hands: Continuous use of computer, telephonic and other electronic equipment. 
  • Communicate: Frequent verbal and written communication.
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • This position primarily works in a climate controlled based setting. The noise level and the work environment are moderately quiet.

Finishing Touches (Preferred):

  • Bachelor’s degree preferred.
  • 2 years of work experience in claims processing (utilizing FACETS) health claims preferred.
  • Healthcare or managed care experience preferred.
  • In-depth knowledge of claims adjudication and medical terminology preferred.
  • 2 years of medical claims research preferred. 
  • 3-5 years of experience as a Research Representative or comparable experience preferred. 

Evolent Health is an Equal Opportunity/Affirmative Action Employer


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