Manager, Resolution Center
Oversight of day-to-day activities of the Resolution Center, including, provider claim issues through CRCTs (claims resolution coordination and tracking); accounts receivable reconciliations/inquiries; PDM (provider data maintenance) management and setup; system configuration architecture, benefit set-up, and auto-adjudication; provider phone representatives (inclusive of in-and out-network); recoupments and recoveries (inclusive of working with TPL and COB vendors), Encounter submissions and pends for all regulatory agencies.
- Ensure appropriate root-cause identification is made, resolved and impacted claims are reprocessed appropriately. This will include working with Reimbursement Services staff, as well as Intra-Departmental staff, including, but not limited to, Information Systems, Network, Contracting, Call-Center, and Internal Audit
- Work directly with providers as requested and appropriate, and may include attendance at Joint Operations Committees
- Responsible to look for opportunities for automation, including, but may not be limited to claims system auto adjudication and robotic processing automation (RPA).
- Develop and maintain internal tracking of all issues, resolutions and appropriate turn-around-time. Information must be maintained in such a manner as to be able to report, including trending
- Responsible to ensure timelines and accuracy in regulatory reporting requirements
- Develop and maintain operational policies and procedures, including Desktops in I-REPP. Ensure updates are timely and accurate
- In conjunction with Training & Development, ensure appropriate training materials and training sessions are available for all Resolutions Center staff
- Develop and maintain job descriptions for Resolution Center staff, cognizant of the organizational changes and how they may impact Resolutions Center operations
- Recommend to leadership changes to operational structure
Education / Experience / Other Requirements
Years of Experience:
Skills & Abilities: