Position Description: Paralegal - Health Insurance SpecialistUnder the direction of the Independent Dispute Resolution Entity (IDRE) Stakeholder Engagement Subject Matter Expert or his/her designee, the Paralegal - Health Insurance Specialist 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. The Paralegal - Health Insurance Specialist 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 Paralegal Health Insurance Specialist will specialize in processing bifurcated state disputes and will complete research on state laws in support of attorneys as requested/required. .In addition to review, the Health Insurance Specialist 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 client
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
Demonstrated skill and experience in handling a large workload with varying deliverable dates
Flexible with assignments to meet contract performance metrics
Specializes in processing of Bifurcated state disputes
Provides preliminary research to support attorneys of state laws as requested and required.
Participate in interdisciplinary collaboration with PRI™ 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
Interact with government and private sector clients, partners, and PRI™ staff in a professional and accountable manner, and as a representative of PRI™
Perform duties of Health Insurance Specialist to ensure contract metrics are met
Perform duties of Eligibility Insurance Specialist
Performs independent dispute resolution review and payment adjudication activities as needed
Perform other duties as requested
Requirements:
Minimum of Bachelor's de ree. Advanced degree in Health Care Administration, Health Care Insurance, or other related field preferred
Additional 4 years of experience in related field may be accepted in lieu of a degree.
Requires 1 year experience as a paralegal
At least 3 years' experience in Health Insurance Claim/Coverage issues or supporting attorneys in healthcare cases or one year of 1 year of experience with the No Surprises Act, preferred.
Superior Data Entry Skills
Ability to thrive in a production-based environment/Ability to multitask, work well under pressure and within timelines
Strong analytical and problem-solving skills with the ability to communicate solutions
Excellent written and verbal communication skills
Reliable and trustworthy; Integrity is required
Excellent organizational skills and ability to pay attention to detail
Ability to contribute to and work effectively within a team environment
Ability to interface with management and contract staff personnel
Proficient user of Microsoft office suite such as Outlook, Access, Excel and Word
Ability to be discrete and maintain confidentiality
Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
Must have no conflict of interest (COI) as defined in 1154(b)(1) of the Social Security Act (SSA)
Ability to obtain and maintain U.S. Government Security Clearance
Preference will be given to those individuals where their primary residency is located in a qualified HUBZone (http://map.sba.gov/hubzone/maps/)FLSA Status: ExemptTeam Member Compensation Plan is applicable to this position.PRI™ is an equal employment opportunity employer. All qualified applicants including Disability/Vets or other qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.Qualified candidates may apply by clicking, "Apply Now". Next, submit your resume. You may complete a cover letter on the following screen. You must contact the employer via one of the methods listed on the screen after clicking "Apply for this job". Please be sure to identify PA CareerLink as your referral source.