IDR Claim Specialist

Gryphon-Healthcare; Houston (TX); On-site; USD 52,000 - 76,000; Full time

Job summary

Gryphon Healthcare is seeking an IDR Claim Specialist to analyze and organize documentation for eligible claims filed with Federal IDR, aiming to resolve billing disputes involving out-of-network providers, facilities, and health plans.

The role includes managing arbitration/mediation processes, preparing documentation packets, and tracking case information in Smartsheets and MS Office tools, while upholding HIPAA confidentiality and delivering strong customer service.

Qualifications

• High School graduate or equivalent required.
• Previous experience in medical billing preferred.
• Ability to interpret Eligibility of Benefits (EOB).
• Maintains confidentiality of patient data per HIPAA.

Responsibilities

• Work daily reports to identify claims eligible for Mediation/Arbitration by insurance type, dates, and EOB dates.
• Prepare Arbitration/Mediation documentation packets for IDR filing, review for accuracy and upload to drive/system.
• Record and track case information via Smartsheets, Excel, Word.
• Identify and communicate IDR trends with Director of Revenue Cycle Management & Legal Team.
• Participate in team meetings and support Legal Team goals and timelines.
• Maintain confidentiality of patient data in compliance with HIPAA.
• Provide support to billing and auxiliary departments as needed.
• Demonstrate good customer service with internal and external customers.

Skills

Attention to Detail

Teamwork

Oral/Written Communication

Computer Skills

Time Management

Professionalism

Ethics and Integrity

Education

High School graduate

Tools

Centricity

Smartsheets

Microsoft Office Suite

Job description

JOB SUMMARY

Federal IDR Claim Specialist is responsible for analyzing, organizing, and preparing documentation for eligible claims to be filed with Federal IDR in effort to promptly resolve billing disputes between out of network providers, facilities, and health plans.

Arbitration: Manages disputes between out-of-network health care providers and health plans

Mediation: Manages disputes between out-of-network facilities and health plans

DUTIES AND RESPONSIBILITIES

• Work daily reports to identify claims eligible for Mediation/Arbitration by identifying insurance type, eligible dates of service and EOB check dates.
• Prepare Arbitration/Mediation documentation packets for filing with IDR by compiling required components, review for accuracy and recording and uploading to appropriate drive/system.
• Record and track all required case information via applicable system (i.e. Smartsheets, Excel, Word).
• Identify and communicate IDR trends with Director of Revenue Cycle Management & Legal Team.
• Participates in team meetings and provides input and feedback to support Legal Team goals, objectives, and timelines.
• Maintains confidentiality of patient data and medical records in compliance with HIPAA guidelines and regulations.
• Perform all other duties and tasks assigned by Management.
• Provides support as needed to all members of the billing and auxiliary departments at Gryphon Healthcare.
• Demonstrates good customer service standards when communicating with internal and/or external customers.

COMPETENCIES

• Attention to Detail – Completes all work according to organization procedures and standards. Double checks the accuracy of information and work product.
• Teamwork - Strong interpersonal and communications skills to be able to work successfully in a team-oriented environment. Active participant within the team and contributes to achieving team objectives
• Oral/Written Communication Skills – Able to communicate information and ideas in a clear concise manner both orally and in written form. Able to convey complex information clearly. Takes time to listen to and understand the perspective of others and propose solutions.
• Computer Skills - Understands and fully utilizes computer systems used in the technological stream of researching and entering claim information including but not limited to: Centricity, Microsoft Office Suite, Smartsheets
• Time Management -Well organized, self-motivated, and able to work with minimal supervision, meet quality and productivity standards
• Professionalism - Demonstrates behaviors consistent with the organization’s core values. Displays an appearance in compliance with the dress code policy
• Ethics and Integrity – Accepts responsibility for one’s own decisions, actions, and failures. Demonstrates knowledge, skills, and ability to determine right from wrong.

EDUCATION AND EXPERIENCE REQUIREMENTS

• High School graduate or equivalent required.
• Previous experience in medical billing preferred.
• Ability to accurately interpret Eligibility of Benefits (EOB)
• Maintains confidentiality of patient data and medical records in compliance with HIPAA guidelines and regulations
• EMR, EDI and Commercial Insurance Company systems
• Ability to represent the company in a professional manner and handle patient issues with sensitivity and confidentiality.
• Detail oriented and accurate data entry skills
• Strong organizational skills and the ability to prioritize workload
• Must be able to write and speak effectively in English
• Must demonstrate interpersonal skills with all levels of the billing and management team
• Must be able to work well in a team environment
• Must have basic computer literacy that includes keyboarding skills with the ability to utilize Outlook and to navigate in a Windows environment.

WORKING ENVIRONMENT

Ability to work in a fast-paced, high volume and dynamic environment.

Requires flexible work hours in order to meet the needs of the team and company.

This position description is not intended to be all inclusive, and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required. Gryphon Healthcare reserves the right to revise or change job duties and responsibilities as the need arises.