WORK FROM HOME
Compile appropriate information to make requested credentialing, contractual, and demographic updates and changes related to provider
data in the systems of record in an accurate, complete and timely manner. Manage and sustain positive provider relationships. Setup
providers and networks in systems of record, assign provider numbers and communicate with provider community. Facilitate accurate
financial claims payment and provider directory processes. Represent BCBSLA to external provider communities and internal stakeholder
NATURE AND SCOPE:
This position reports to the Supervisor, Provider Information.
Activities of Direct Reports:
This position has no reports.
In order to effectively fulfill this position the incumbent must be in contact with:
Network Operations, EDI, Network Development, Provider Services, Customer Service Units and other internal departments as needed;
regulatory agencies, facility providers, practitioner providers, office managers, and provider licensing agencies.
High School diploma or equivalent is required. Prefer an Associate or Bachelor’s degree in business or health related field
Two years of customer service, credentialing, enrollment and billing, claims and/or insurance operations experience is required.
Demonstrated knowledge of insurance services and operations.
Facets, IPD, Provider Manager, and Cactus knowledge preferred.
Prior claims processing experience preferred.
Strong analytical skills/problem solving skills.
Critical thinking/ability to question.
Provider (customer) focused.
Interpersonal skills/relationship building.
Excellent communication skills with internal and external stakeholders; ability to effectively communicate with provider community in a
Ability to multitask in a fast-paced production environment.
Strong organizational skills/Time management.
Takes accountability for work performed.
Ability to work both individually and in a team environment with shared goals.
Ability to work under pressure to produce high quality work with defined turnaround goals.
Ability to effectively adapt to change.
ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS:
Accurately setups providers in provider systems of record to ensure appropriate claims payment in accordance with contractual language.
Compiles, analyzes, and verifies the required information for provider enrollment, contracts, and maintenance for completeness and
accuracy, and enter it into the systems of record.
Communicates, orally and in writing, directly with providers to resolve questions and issues regarding updates and changes in the systems
Researches, responds to, analyzes and resolves complex claims issues related to provider setup and provider eligibility on a daily basis.
Creates resolution documents to address provider issues and increase provider satisfaction. Utilizes probing and problem solving methods to
resolve all inquiries/requests. Identifies, understands and anticipates providers unexpressed needs and concerns.
Provides cross functional support and serves as subject matter resource or second tier resolution to internal and external provider teams
(i.e., Contracting, Provider Relations, etc.).
Manage timely responses to external provider inquiries and requests. Evaluate new service requests from providers to determine appropriate
actions for recording into the systems of record.
Recommend, and participate in process improvement opportunities for Network Management Operations.
Identify system problems, gaps or inconsistencies in workflows and/or processes. Recommend appropriate updates, alternatives and
Accountable for complying with all laws and regulations associated with duties and responsibilities.
The physical demands described here are representative of those that must be met by an employee to successfully perform the
accountabilities (essential functions) of the job. Reasonable accommodations may be made to enable an individual with disabilities to
perform the essential functions.
Job duties are performed in a normal and clean office environment with normal noise levels.
Work is predominately done while standing or sitting.
The ability to comprehend, document and analyze are all required.