Responsibilities
•    Assist and educate 1199SEIU members and providers with out-of-network fees and out of pocket expenses on the contracts and benefits of using the Funds network 
•    Negotiate and resolve large volume of balance billing inquires fees and discounts for members 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). This includes leveraging communication and negotiation strategies to achieve mutually agreeable payment solutions. Assess claim details and potential outcomes to determine when negotiation is more beneficial than escalating to IDR, utilizing various benchmarks 
•    Utilize the various databases to assess and compute reasonable rates, negotiating claim payments with providers, attorneys, and collection agencies on behalf of members 
•    Proactively identify and communicate any barriers to achieving departmental objectives to management 
•    Analyze received correspondence; verify member eligibility, claim history and coordination of benefits 
•    Identify billing anomalies and alert the appropriate departments to reduce potential fraudulent billing practices. 
•    Review claims to assess if appropriate action was taken and collaborate with various departments to implement corrections 
•    Research provider contracts and lease network reports to ensure providers are not breaching contracts by referring members out of network; report noncompliant providers to the Network Management and Contracting departments 
•    Identify potential opportunities to contract providers and refer to the Network Management and Contracting departments 
•    Triage balance billing/fee negotiation inquiries and ensure all documents are processed in a timely and efficient manner 
•    Perform special projects and other duties assigned by management

Qualifications
•    High School Diploma required, Associate degree or equivalent’s degree highly preferred  
•    Minimum two (2) years of hospital and medical claims processing experience, including at least two (2) years of negotiation experience required.
•    Proficient in math skills and the ability to perform calculations for negotiations are required 
•    Strong knowledge of health claims, eligibility rules, and Coordination of Benefits (COB) is necessary
•    Basic understanding of the No Surprises Act (NSA), including experience with surprise billing protections, Independent Dispute Resolution (IDR) processes, and the Qualified Payment Amount (QPA)
•    Excellent critical thinking, attention to detail, and problem-solving skills; able to work independently and collaboratively as part of a team
•    Demonstrate analytical and organizational skills with the ability to multitask and meet operational deadlines
•    Proficiency in Microsoft Office (Word, Excel, Outlook, etc.). Ability to grasp and utilize new software systems 
•    Ability to work well under pressure, maintain a professional manner, and presentation