Health Event Adjudicator

Date Posted: 

June 16, 2022

CrowdHealth is helping Members live boldly without the fear and stress related to health care bills. No doctor networks. No huge monthly premiums. No annual deductibles. No surprises.

www.joincrowdhealth.com

Purpose

To validate and negotiate health events submitted by CrowdHealth Members for funding, and to provide assurance and confidence that all contributions fund valid, high-quality, fairly priced health care

Scope

The Health Event Adjudicator will support the Crowd by ensuring the validity and fairness of health care expenses through:

  • Evaluating submitted health events/bills for crowdfunding eligibility,
  • Adjudicating bills,
  • Assessing Member health events for possible preexisting conditions, and
  • Negotiating bills.

Reports to the Director of Operations.

Outcome

CrowdHealth Members have complete peace of mind that their financial contributions are helping crowdfund high-quality, fairly priced health care for other Members, and Members’ valid health events are handled quickly and painlessly. Measured by rates of validated bills and successful preexisting condition identification, health care savings when compared to market standard/average, revenue produced from negotiated savings, and health event processing time.

Responsibilities

Health Event Eligibility Evaluation

  • Develop acute understanding of the terms of CrowdHealth Membership, including the Member Guide policies and the eligibility of medical treatments and procedures.
  • Review all Member health events within two business days of initiation by Member.
  • Evaluate all Member health events for funding eligibility based on terms of Membership.
  • Work closely with Care Advocate regarding any necessary Member communications related to health event creation, validation or denial, and resolution.
  • Use learnings from real Member health events to provide collaborative input and help make CrowdHealth funding policies simpler, clearer, and more easily understood by Members.

Bill Adjudication

  • Screen all eligible Member health expenses, including but not limited to:
  • Reviewing CPT codes,
  • Confirming that billed services were provided, and
  • Considering levels of care billed match Member need/experience.
  • Communicate with medical practitioners and billing offices to fill information gaps as needed.

Preexisting Condition Evaluation

  • Assess all Member health events for possible presence of preexisting conditions, including:
  • Accessing Member medical records through HIPAA-compliant process,
  • Reviewing records in detail for relevant information, and  
  • Working closely with Care Advocates to gain understanding of Member situations and health conditions.
  • Collaborate with CrowdHealth team members involved in crowdfunding process to ensure appropriate limits are applied to funding of preexisting conditions.

Bill Negotiation

  • Reduce health care costs funded by the Crowd by actively negotiating smaller medical bills (generally $1K-$10K).
  • Cooperate with Head of Product to support and engage relationship with vendors who manage negotiation of larger bills (generally $10K+).
  • Calculate savings to the Crowd and resulting amount of CrowdHealth revenue (20% of savings) when bills are successfully negotiated.

Qualifications

College degree in accounting, human resources, or similar, and/or professional healthcare credentials, with at least five years of experience in healthcare administration. Must possess a passion for helping people overcome a complicated and burdensome U.S. healthcare system.

Skills

  • Thorough understanding of health care billing processes, jargon, and procedure codes, to evaluate legitimacy of medical bills submitted by Members.
  • Critical thinking and active learning, to gain complete understanding of Member health events.
  • Commitment to processes and strong time and energy management, to simultaneously handle multiple health events in various and changing statuses.
  • Sincere curiosity and problem solving, to help CrowdHealth continuously improve upon and simplify the health event process for Members.
  • Proficiency at technology, with experience using CRM software such as ZenDesk and ability to learn the CrowdHealth mobile application and advocate portal.
  • Detail oriented, with a keen eye for medical billing nuances and a precise understanding of CrowdHealth Membership details and benefits.
  • Negotiation and effective persuasion, to successfully reduce medical bill amounts while building positive relationships with medical practitioners.
  • Commitment to teamwork, to support other Member-facing teammates in their work to create a positive Member experience from all sides.
  • Connections and a well-respected reputation within the healthcare sector, to support growth of the CrowdHealth platform and Member Community.

To apply please email your resume to hey@joincrowdhealth.com