The Phia Group is a service-oriented consultant that assists health plans nationwide and internationally. We provide our clients with innovative cost-cutting solutions and innovative service offerings. As employers/payers seek to identify reasonable prices for healthcare while protecting their employees/members against abusive practices, they encounter conflicts from many directions. One area of emphasis is the clinical and coding aspects of a claim. One area of concern is balance-billing: the practice by some providers of medical services to seek payment of amounts in excess of payments made by health plans, from patients and/or employers.

The Complex Claims Specialist will be responsible for negotiating settlement with facilities and providers for domestic and international clients to reduce healthcare claims costs, among many other tasks. This position requires someone that is proactive, persuasive, persistent, respectful, assertive. Complex Claims Specialist must have excellent problem-solving skills both with medical providers and external partners. They will also be integral to the repricing team, offering essential expertise and assistance in research endeavors. Additionally, they will be responsible for maintaining standard operating procedures under the guidance of Provider Relations’ management.

At The Phia Group, whose mission is to provide high quality yet affordable healthcare to American employees and their families, you can look forward to not only unparalleled benefits for yourself but also being immersed in a company, one that recently celebrated its 25th anniversary, named one of USA Today’s Top Workplaces for 2025. Meanwhile, Louisville Business First also recognized our unwavering commitment to upholding an internal culture of inclusivity, enjoyment, and empathy for our valued employees by listing The Phia Group among its 2025 Best Places to Work.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Manage a daily running inventory of unpaid claims or claim disputes.
• Engage service providers on pre-service or pre-claim negotiations and single case agreements
• Ability to handle high dollar claims under sensitive timelines
• Appropriately escalate client issues and or concerns on high touch negotiations
• Help pull timely KPIs for relevant client support team
• Participate in specialized projects focused on coding, benchmarking and clinical considerations.
• Review and prioritize claims based on processing criteria, timelines, client demands, and service level standards.
• Contact facilities and providers to discuss charge adjustments and rationale.
• Contact facilities and explain benefits to resolve payment disputes.
• Draft correspondence pertaining to settlement and negotiation efforts for providers and other entities.
• Capture detailed notes on calls for future reference, both internal, external clients and providers and collection offices.
• Work with the Provider Relation’s escalation team to ensure proper handling of complicated cases.
• Participate in on-going process improvement to develop efficiencies that streamline the handling of all cases.
• Ability to properly handle confidential information in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

Experience and Qualifications

• A minimum of four years’ experience in a medical healthcare claims role, preferably involving negotiation, or experience at an insurance company, TPA, or hospital, preferably with emphasis in claims, fee schedules, or contracting.
• Computer literate, including Microsoft Office products.
• Strong data literacy skills with the ability to triage, wrangle, and interpret data sources.
• Excellent communication skills

Working Conditions / Physical Demands

Sitting at workstation for prolonged periods of time. Extensive computer work. Workstation may be exposed to overhead fluorescent lighting and air conditioning. Fast paced work environment. Operates office equipment including personal computer, copiers, and fax machines.

This job description is not intended to be and should not be construed as an all-inclusive list of all the responsibilities, skills or working conditions associated with the position. While it is intended to accurately reflect the position activities and requirements, the company reserves the right to modify, add or remove duties and assign other duties as necessary.

External and internal applicants, as well as position incumbents who become disabled as defined under the Americans with Disabilities Act, must be able to perform the essential job functions (as listed here) either unaided or with the assistance of a reasonable accommodation to be determined by management on a case by case basis.

Base Salary: $55,000 - $65,000