Job Summary:

Resolves escalated member and provider inquiries including but not limited to international bills, out-of-state bills, and reimbursements in accordance with contractual and regulatory guidelines.  Responds to member and provider inquiries verbally and/or in writing as needed.  Acts as point person for management and partner departments related to all HIPAA, privacy, and confidentiality issues. 

KEY FUNCTIONS/RESPONSIBILITIES:

• Facilitates payment of out-of-state or out-of-country claims, including any related provider and member outreach
• Communicates verbally and in writing with providers to educate them on balance billing practices and ensure members are billed (or not billed) in accordance with applicable contractual and regulatory guidelines
• With assistance from department leadership, handles rate negotiation with nonpar providers to resolve member balance billing issues
• Serves as a HIPAA and confidentiality policy subject matter expert within the department, including current privacy practices of the Division of Insurance, Centers for Medicare and Medicaid Services, Department of Health and Human Services, the Executive Office of Health and Services, and theCommonwealth Connector Authority
• In conjunction with Member and Provider Service's training team, and in accordance with WellSense corporate compliance policies, creates HIPAA and related state, contractual and regulatory privacy and confidentiality, procedures, workflows, and training materials for the Member and Provider Service area
• Collaborates with Member and Provider Service training team to ensure that new and existing staff are educated on HIPAA and all related state, contractual and regulatory privacy and confidentiality policies, procedures, and workflows by delivering and coordinating training
• Communicates with Public Partnerships, Compliance, and the Legal departments on compliance-related issues
• Outreaches to providers who require the transfer of members from their panels in accordance with plan requirements 
• Handles calls that are escalated due to a member or provider's dissatisfaction
• Oversees timely and efficient processing of PCP change forms, returned mail, and health assessment surveys
• Manages negative balance issues for providers
• Makes outbound calls to members and providers that could not be handled as a first call resolution (FCR)
• Makes orientation and re-determinations calls
• Responsible for ensuring TTY phone is managed in accordance with department expectations, including ensuring TTY phone coverage during business hours
• Maintains the department mailboxes and ensures work is completely timely
• Makes claims adjustments as needed
• Handles all incoming e-mail and responds to members appropriately
• Manages the member reimbursement process for out-of-pocket expenses
• Provides excellent customer service to members and providers on high profile or escalated issues
• Performs other duties as assigned

QUALIFICATIONS:

EDUCATION:

• Associate’s Degree or the equivalent combination of training and experience, plus 1-3 years of related experience

EDUCATION PREFERRED/DESIRABLE:

• Bachelor’s Degree or the equivalent combination of training and experience, plus 1-3 years of related experience.

EXPERIENCE:

• A Minimum of 3 years of Medicaid call center experience
• A minimum of 2 years handling escalated member inquiries (i.e. appeals or billing inquiries)

EXPERIENCE PREFERRED/DESIRABLE:

• Previous experience in a healthcare/insurance field is preferred.

COMPETENCIES, SKILLS, AND ATTRIBUTES:

• Ability to handle confidential material in a secure manner
• Expertise in privacy regulations and practices
• Thorough understanding of Medicare and Medicaid programs and the respective member benefits, cost sharing, rights and responsibilities, as well as provider responsibilities
• Effective collaborative and proven process improvement skills
• Strong oral and written communication skills; ability to interact within all levels of the organization
• Demonstrated ability to successfully plan, organize and manage projects
• Detail oriented, excellent proof reading and editing skills
• A strong working knowledge of Microsoft Office products

*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