Position Summary

The Collections and Claims Examiner I is responsible for processing submitted electronic claims to ensure proper filing procedures and that processing guidelines and rules have been followed. The Collections and Claims Examiner I also validates claim or referral submissions to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre-coding requirements.

Duties and Responsibilities

• • Conduct analysis around various claims payment processes to ensure accuracy of system configuration and provider payments.
• • Investigate and resolve problem claims, while focusing on improving errors and problems to prevent future occurrences.
• • Perform and execute various claims process testing requests to ensure desired results are met to support accurate claims payments.
• • Analyze and adjudicate complex claims that cannot be auto adjudicated.
• • Adjudicate claims by, including but not limited to, applying medical necessity guidelines, determining coverage and completing eligibility verification, identifying discrepancies and applying all cost containmentmeasures.
• • Process medical claims by approving or denying documentation, calculating benefits due initiating a payment or denial letter.
• • Follow any center for Medicare and Medicaid (CMS) changes affecting claimsprocessing.
• • Perform pre-payment audit.
• • Follow company policies, procedures and guidelines to ensure legal compliance.
• • Update claims knowledge by participating in educational opportunities, whether system oriented or medical coding/terminology/interpretation.
• • Update and maintain departmental and specialty network standards of operating procedure(SOP).
• • Complies with performance standards as set forth by the department head.
• • Perform posting charges and completion of claims to payers in a timely fashion.
• • Assume the responsibility of receiving and sorting incoming payments with attention to credibility.
• • Following up on unpaid claims within standard billing cycle timeframe – Handle collections on unpaid accounts.
• • Accurately Post all insurance payments by line item.
• • Calling Insurance Companies regarding any discrepancy in payments if necessary – Timely follow up on insurance claim denials, exceptions or exclusions.
• • Reading and interpreting insurance explanation of benefits.
• • Obtaining referrals, medical records and authorizations as required for procedures -Make necessary arrangements for medical records requests, completion of additional information requests, etc. as requested by insurance companies.
• • Respond to inquiries from insurance companies and providers.
• • Investigate, researching and appealing denied claims
• • Regularly meet with VP of Operations – to discuss and resolve reimbursement issues or billing obstacles.
• • Updating monthly payments spreadsheets, running payment reports and current collections reports.
• • Monitor and follow up with the Health Plans regarding the aging’s.

Knowledge

• • Minimum of 1- year of Claims Adjustment experience/ previous claims processing experience.
• • Knowledge in Podiatry, Orthopedic, Dermatology and/or Pain Management specialties preferred.
• • Knowledge of HIPAA policies and Compliance.
• • Medical Terminology including ICD (10) and CPT Knowledge.
• • Associates degree preferred

Skills

• • Proficient in Microsoft Office programs.
• • Previous experience with systems processing.
• • Research skills

Abilities

• Data Entry and Documentation skills
• Problem solving, Analytical and verbal communication skills
• Ability to interpret medical documentation
• Detailed oriented

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 7:00 a.m. to 6:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Travel

This position requires less than 10% travel.

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Position Summary

Supports the Provider Servicing Manager to achieve department goals. Answers incoming telephone inquiries from groups and assists with problem resolution of issues. Coordinates network group submissions, such as, group updates, monthly rosters, group applications and group listings to internal departments and external customers (i.e. health plan partners, PCPs and network groups).

Duties and Responsibilities

• • Supports the Provider Servicing Specialist with all network group inquires.
• • Provides oversight on inquiries and claims issues following up with respective internal departments and network groups to ensure issues and/or needs have been resolved. Providing Internal departments with any paperwork needed to take care of claims issues. Responds to Network groups and/or health plan partners to close the loop on any inquiries, issues and/or open items.
• • Reviews and processes incoming and outgoing paperwork for existing groups and network update email request and all other related functions in accordance with the department’s Policies and Procedures.
• • Liaison, in conjunction with the Provider Servicing Specialist, for all health plans.
• • Audits all group-submitted requests, associated documents, and files according to the department’s Policies and Procedures for all health plans.
• • Configures group loads on active group updates such as demographic changes, terminations, new lines of business, reimbursement changes, etc. and enters all updates into networks proprietary database.
• • Performs BatchGeo for all contract terminations, location terminations and new group location request in accordance with the department’s Policies and Procedures.
• • Bi-Monthly Group Attestations sent and ensured they are received back signed by groups. This is mandatory to obtain and store in Networks proprietary database.
• • Quarterly expiration reports check to ensure that all expired documents for groups are received within the quarter and stored in networks proprietary database.
• • Sends via email, fax blast and/or certified mail required provider notification and letters.
• • Liaison between Groups to provide Contracting detailed information requested.
• • Special Projects as assigned or directed.

Knowledge

• • Associate’s degree preferred or equivalent directly related experience.
• • Minimum 1+ years’ experience in customer service or claims with exposure to problem resolution.

Skills

• Excellent problem-solving skills
• Proficient oral and written communication skills
• Deductive Reasoning
• Works well individually and/or with team setting
• Intermediate Microsoft Office skills
• Bi-lingual a plus

Abilities

• Organizational skills
• Excellent time management
• Analytical mind frame for reviewing of data

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 8:00 a.m. to 5:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Travel

This position requires less than 5% travel.

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Position Summary

Manages all Specialty Physician networks by developing and maintaining relationships to drive business results within a specific geographic area. Provides service and education to Network groups and staff. Achieves company targets through implementation of the policies and procedures.

Duties and Responsibilities

• • Completes new group orientations within thirty (30) days of health plan effective date for all applicable health plan partners’ product lines.
• • Conducts monthly site visits to resolve issues, educate new staff/groups on policies, collect new/updated credentialing information and review any changes/updates to the Network Manual or Network guidelines.
• • During initial onboarding, meets with the appropriate Network Group personnel and fully explains the company’s protocols, including but not limited to, all requirements necessary to comply with standards identified in the Network Manual.
• • Achieves quarterly servicing goals to establish consistent and strong relationships with Network Group offices.
• • Provides oversight and education to Network Groups on inquiries and claims issues and follows-up with Network Group and Network Servicing Coordinator to ensure issues have been resolved.
• • As applicable, will forward identified network gaps to the Director of Contracting, Servicing and Credentialing to fill the deficiencies.
• • Liaison, in conjunction with Network Servicing Coordinator, to all health plans.
• • Understands and explains network group contracts, if needed.
• • Strategizes for network groups and health plan retention.
• • Special projects as assigned or directed.
• • Exercises discretion and independent judgment in matters involving the servicing of providers.
  Knowledge
• • A Bachelor’s Degree in a related field or equivalent related Network Development or Provider Relations experience.
• • Minimum three (3) years’ experience in Medicaid/Medicare is preferred.
• • Healthcare, provider office or HMO/PPO background preferred.
• • Strong knowledge of regulatory requirements concerning Medicare and Medicaid preferred.

Skills

• • Excellent problem-solving skills.
• • Proficient oral and written communication skills.
• • Bilingual language skills a plus.
• • Intermediate Microsoft Office skills.
• • Deductive Reasoning
• • Works well individually and/or with team setting

Abilities

• • Must be organized and have excellent time management capabilities.
• • Ability to analyze data to identify trends and variance from goals.

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 8:00 a.m. to 5:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Travel

Yes, 95 % of the time or as otherwise required by the company.

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.