Acts as the primary liaison between Provider Relations Consultants and internal Plan departments such as Claims, Benefits, Audit, Member and Provider Enrollment and Clinical Services to effectively identify and resolve claim issues. Works closely with the leadership team to identify issues and report trends.
KEY FUNCTIONS/RESPONSIBILITIES:
- Investigate, document, track, and assist with claims resolution.
- Interact with various operational departments to assure accurate and timely payment of claims in accordance with the plan's policies and procedures.
- Identify system changes impacting claims processing and work internally on resolution.
- Identify systematic issues and trends and research for potential configuration related work.
- Analyze trends in claims processing and assist in identifying and quantifying issues.
- Run claim reports regularly to support external provider visits.
- Develop and enhance our physician, clinician, community health center and hospital relationships through effective business interactions and outreach.
- Act as liaison for all reimbursement, issues with providers. Facilitates resolution of complex contractual and member/provider issues, collaborating with internal departments as necessary.
- As needed, provides general education and support on BMCHP products, policies, procedures and operational issues.
- Manages flow of information to and from internal departments to ensure communication regarding Plans changes and updates.
- May outreach to providers according to Plan initiatives.
- Facilitates problem resolution. Initiates Plan interdepartmental collaboration to resolve complex provider issues.
- Identifies system updates needed and completes research related to provider data in Onyx and Facets.
- Processes reports as needed to support provider education, servicing, credentialing and recruitment.
- Ensures quality and compliance with State Agencies and NCQA.
- Other responsibilities as assigned.
- Understanding and implementation of Plan polices & procedures.
- Regular and reliable attendance is an essential function of the position.
QUALIFICATIONS:
EDUCATION:
- Bachelor’s degree in Business Administration, related field or an equivalent combination of education, training and experience is required.
EXPERIENCE:
- 2 or more years of progressively responsible experience in a managed care or healthcare environment is preferred.
- Experience with Medicare and Medicaid Reimbursement Methodologies.
- Understanding of provider coding and billing practices.
CERTIFICATION OR CONDITIONS OF EMPLOYMENT:
- Must have valid drivers license and access to a car.
COMPETENCIES, SKILLS, AND ATTRIBUTES:
- Experience with ICD-10, CPT/HCPCS Codes, and billing claim forms.
- Ability to work as a team member, to manage multiple tasks, to be flexible, and to work independently and possess excellent organizational skills.
- Proven expertise utilizing Microsoft Office products.
- Effective communication skills (verbal and written).
- Strong follow-up skills.
- Proficient in multi-tasking.
- Ability to set and manage priorities.
WORKING CONDITIONS AND PHYSICAL EFFORT:
- Travel up to 75%. Service area is Southeast.
*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.
Required Skills
Required Experience