Job Description

Location: Health Choice Management Co.
Posted Date: 5/12/2020

Position Purpose:

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.

Responsibilities:

  • 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

Education:

  • Bachelor’s Degree Preferred

Years of Experience:

  • 3+ years of managed care experience
  • 5+ years of people supervision

Specialized Knowledge:

  • Claims processing, information systems, customer service, call center, provider relations, Encounter submission
  • Leadership
  • Reporting and presentations
  • Claims Processing Systems
  • Managed care claims processing systems, including provider setup and benefits
  • Trend Reporting
  • Provider reimbursement cycle

Skills & Abilities:

  • Must be able to effectively communicate with internal and external customers via telephone and email.
  • Able to accurately receive information through oral and written communication
  • Able to accurately review data and figures both in hard copy and electronic formats
  • Able to accurately sort through data and think through issues in a timepressured environment.
  • Able to maintain a calm and collected presence while addressing the concerns from an internal and external customer
  • Able to accurately learn and retain new information, knowledge and skills
  • Able to efficiently manage multiple task, with varying degrees of priority, at the same time

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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