Kavaliro · 3 days ago
Claims & Benefits Resolution Specialist
West Valley City, UT
Contract
Hybrid
Entry, Mid Level
2+ years expKavaliro is seeking a Claims & Benefits Resolution Specialist for a contract opportunity. The role involves performing comprehensive audits and resolution activities across the claims lifecycle, ensuring accurate billing and compliance with payer requirements.
B2BConsultingDeliveryHuman ResourcesInformation Technology
Responsibilities
Claims Audit & Correction
Perform comprehensive audits on assigned accounts to identify billing, payment, and adjustment errors
Correct claim discrepancies within established turnaround times
Ensure claim data accuracy, compliant coding, and alignment with the member’s plan benefit
Timely & Accurate Claims Processing
Process claims quickly and accurately according to organizational benchmarks
Apply reimbursement rules based on the member’s benefits and plan specifications
Validate supporting documentation needed for accurate processing (eligibility, benefits, authorizations, etc.)
Complex Follow-Up & Dispute Resolution
Conduct follow-up on delayed, denied, or pended claims; escalate unresolved items as needed
Investigate processing delays, missing information, or system errors and implement corrective action
Refer cases to clinical management teams when medical review is required to ensure appropriate reimbursement
Eligibility, Benefits & Authorization Coordination
Verify and document member eligibility, benefits coverage, and authorization requirements
Identify discrepancies in coverage or authorizations that impact payment determinations
Communicate directly with payers or internal departments to resolve missing or inconsistent benefit information
Cross-Functional Collaboration
Work closely with leadership, clinical review staff, and the CBO team to ensure timely resolution of claim issues
Participate in problem-solving discussions related to claim trends or systemic issues
Support training and onboarding efforts as needed during onsite sessions
Qualification
Required
Minimum 2+ years of experience in healthcare revenue cycle, claims processing, eligibility/benefits, or authorizations
Strong understanding of payer rules, reimbursement methodologies, and claims adjudication
Familiarity with Epic, payer portals, and other claims/RCM systems
High accuracy in auditing and error resolution work
Experience resolving complex claim issues across multiple systems
Ability to work independently, troubleshoot problems, and drive claims to completion
Strong communication skills for interacting with payers, internal teams, and leadership
Comfortable with onsite onboarding and required monthly onsite days
Experience working in a Central Business Office or Shared Services model
Prior experience supporting Utah-based payer populations or multi-state payer networks
Company
Kavaliro
Kavaliro is a staffing and recruiting company that offers IT, management, and administrative staffing services.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Mark Moore
Co-Founder and President
Recent News
The Business Journals
2023-12-23
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2023-06-21
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