This position will be responsible for daily provider telephone calls which will include problem solving, eligibility, benefit, and resolution of claims issues. Assists in providing linkage to the Medical Management Department for authorization of services. Being an advocate for the Provider, supplying information and education, working with Network Development to handle issues. Also responsible for assisting members with eligibility, benefit, and resolution of claims issues as needed.
Essential Functions and Responsibilities:
- Meet the Department call metric standards and issues/diaries entered.
- Assist Providers and Members as needed with questions and concerns.
- Answer billing/claims status questions; resolve claim issues for providers
- Assist with pharmacy issues
- Verify member eligibility
- Quote benefits
- Assist with Referrals
- Ongoing Provider education.
- Responsible for all benefits information given to Providers and Members.
- Participate in Departmental Projects, as appropriate.
- Coordinate quality improvement initiatives with Medical Management Dept., Network Development, i.e., HEDIS improvement, Provider education.
- Other duties as assigned or when necessary to maintain efficient operations of the department and the Company as a whole.
- High School Diploma or equivalent certification
- Two (2) years’ experience in a high volume call center
- Two (2) years’ experience in a Physician front office environment
- In-depth understanding of claims administration as it pertains to provider payments, including CPT-4 codes, revenue codes, HCPCS codes, DRGs, etc.
- Associate’s Degree in business, health care or related field. An equivalent combination of relevant education and experience may be substituted for the educational requirement