About Us: Building Services 32BJ Benefit Funds ("the Funds") is the umbrella organization responsible for administering Health, Pension, Retirement Savings, Training, and Legal Services benefits to over 100,000 SEIU 32BJ members. Our mission is to make significant contributions to the lives of our members by providing high quality benefits and services. Through our commitment, we embody five core values: F lexibility, I nitiative, R espect, S ustainability, and T eamwork ( FIRST). By following our core values, employees are open to different and new ways of doing things, take active steps to improve the organization, create an environment of trust and respect, approach their work with the intent of a positive outcome, and work collaboratively with colleagues. For 2023 and beyond, 32BJ Benefit Fundswill continue to drive innovation, equity, and technology insights to further help the lives of our hard-working members and their families. We use cutting edge technology such as: M365, Dynamics 365 CRM, Dynamics 365 F&O, Azure, AWS, SQL, Snowflake, QlikView, and more. Through this technology investment, we have gathered and analyzed thousands of data insights to influence health insurance legislation and propose new health policy. Our efforts have galvanized many leaders and the consensus is there is plenty more work to be done. Please take a moment to watch our video to learn more about our culture and contributions to our members: youtu.be/hYNdMGLn19A Summary: Reporting to the Manager of Health Fund Operations, on an interim basis, the Clinical Dispute Resolution Specialist is responsible for providing support to the Clinical Manager in managing and overseeing the Independent Dispute Resolution process within our organization. This role requires a strong clinical background to assess medical necessity in disputed cases, alongside proficient data entry and case management skills to handle submissions, documentation, and communication with insurance companies and healthcare providers. Principal Duties and Responsibilities: Case Review and Assessment Conduct thorough review of disputed medical claims to determine the medical necessity of services provided to our members Analyze clinical documentation to support or contest payment disputes Collaborate with healthcare providers to obtain necessary clinical information and provide expert clinical insight during negotiations IDR Process Management Coordinate the submission of notices and required documentation through various methods of receipt Ensure compliance with federal regulated 30-day open negotiation period and timelines for IDR requests. Manage the workflow of IDR cases from initiation through final resolution. Data Entry and Documentation Accurately input case details, clinical data, and communications into internal system. Maintain records of all correspondence, decisions, and outcomes related to IDR cases. Ensure all documentation is complete and compliant with federal regulations. Communication and Coordination Serve as liaison between healthcare providers, facilities, air ambulances, and insurance company Facilitate communication between clinical teams and administrative staff to ensure accurate and timely submissions Assist in drafting, editing and updating SOPS. Regulatory Compliance Stay updated on federal regulations to the No Surprises Act and IDR process in conjunction with internal Health Fund policy team Ensure all actions and submissions are in full compliance with federal regulatory requirements. Support the maintenance of a resource database. Maintain up-to-date knowledge of resources and entitlements. Reporting Assist in generating reports on IDR case outcomes, trends, and performance metrics Assist in building presentations to report findings to internal and external stakeholders. General Maintain up-to-date knowledge of Fund benefits Participate in planning and administration of special projects as assigned Perform other duties as assigned. Qualifications and Core Competencies: To perform the job satisfactorily, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Bachelor's degree in Nursing, Health Services, Pharmacy or related vocational program field 5 years experience in case management in a hospital or insurance setting, or similar managing claims 2 years of experience as a Registered Nurse (RN), Licensed Vocational Nurse (LVN), Physician Assistant (PA), or similar clinical credential Strong understanding of medical necessity criteria and clinical documentation standards Proficiency in data entry, with attention to detail and accuracy Experience with healthcare billing and systems is a plus Excellent verbal, interpersonal, and written communication skills Ability to communicate complex medical and regulatory information clearly and effectively Ability to manage multiple cases simultaneously and meet strict deadlines Experience with the Independent Dispute Resolution process or similar healthcare arbitration processes Strong knowledge base of the healthcare industry Outstanding analytical and problem-solving skills Ability to use Microsoft Office with emphasis on Excel and Word Excellent organizational and prioritizing skills Ability to work on simultaneous projects with diverse working groups Excellent customer service skills when working with claimants and hospitals to resolve disputes, answer questions and provide solutions related to medical claims. Language Skills: The ability to read, write and understand English is essential Bilingual in English/Spanish preferred Education: Bachelor's degree in Nursing, Health Services, Pharmacy or related vocational program field
Job Title
BLDG SVC 32 B-J | Clinical Dispute Resolution Specialist (Medical)