This position will be responsible for daily member telephone calls which will include directing members to the proper services needed, educating members, problem solving, and creating linkages to the Medical Management Department for authorization of services. Also responsible for assisting providers with eligibility, benefits, and resolution of claims issues.
High School Diploma or equivalent certification
Two (2) years’ experience in a high-volume call center
In-depth understanding of claims administration as it pertains to provider payments, including CPT-4 codes, revenue codes, HCPCS codes, DRGs, etc.
Associate Degree in business, health care or related field. Two (2) years’ experience and knowledge of HMO, PPO, TPA, PHO and Managed Care functions (e.g. accounting/finance, reinsurance, EDI, marketing, administration, medical delivery, regulatory compliance, claims processing, membership/eligibility, contracting and risk arrangements and actuarial precepts).