Job details
Job type full-time
Full job description
Summary of position
Responsible for receiving, researching and resolving inquiries and requests from internal emblemhealth/connecticare departments and business partners (i.e., account management, provider network management, provider file operations,client retention, access to care, care café, membership, cob, contact center, g&a, etc.) regarding claim outcomes.
Perform root cause analysis and take appropriate steps to have corrected, working directly with support area (emblemhealth/connecticare & cts) as needed.
Recommend changes in procedures, desk level procedures (dlps) and workflow to improve quality and efficiency as needed.
Ensure impacted claims are adjusted.
Oversight and quality review of cts performance.
Provide response to requestor using “speak human” terminology.
Duties and reponsibilities:
Serve as claim processing subject matter expert (sme) for resolution of issues related to claims processing and adjudication outcomes for medical, hospital, dental claims for all emblemhealth/connecticare lines of business as requested by emblemhealth/connecticare business partners or cts business partners.
Research and resolve claim issues as requested and make determination of appropriateness of claim adjudication outcome and/or adjustment request.
Provide oversight and quality review of cts performance of the claim adjustments required.
Perform root cause analysis and take appropriate actions to ensure root cause is remediated.
In addition to requesting configuration updates, remediation may include recommendation of changes to processing procedures, facets workflow and desk level procedures (dlps).
Collaborate with emblemhealth/connecticare and cts business partners as needed to validate accuracy of benefit configuration, networx rate sheets, provider participation status, provider file and membership file, including cob flags impacting the claim(s) adjudication outcome.
Manage high priority/high visibility projects to completion including manual or mass recycles and adjustments.
Ensure issue is closed, providing documentation with appropriate level of detail in “speak human”, including claim adjustment detail or explanation for payment correctness to the requestor
Perform other related projects and duties as assigned
Education, training, licenses, certifications bachelor’s degree, preferably in business management relevant work experience, knowledge, skills, and abilities:
3+ years of managerial/supervisory experience within a related health care and/or claims environment
Additional years of experience may be used in lieu of educational requirements
3+ years in claims processing with working knowledge of medical terminology, provider reimbursement, icd-10, hcpcs and cpt-4 coding, coordination of benefits
Strong knowledge of claims processing, procedures and systems, state, federal and medicare regulations and coordination of benefits applications
1-3 years’ experience managing in a bpass model
Strong knowledge of member and provider contracts, procedures and systems
Prior proven emblemhealth experience
Strong planning, organizational, interpersonal, verbal and written communication skills.
Must be pc literate and possess a strong understanding of microsoft applications
Ability to handle multiple priorities and meet deadlines.
Additional information
Job type: standard
Schedule: full-time
Employee status: regular
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Job activity
Posted 15 days ago
