This position receives/responds to in- and out-of-network provider inquiries on claim status (payment, denials, rejections, appeals, recoupments, etc.), education on Explanation of Payments and provider portal questions, and other concerns and/or complaints. The appropriate resolution is provided via researching information by reviewing plan, eligibility, and authorizations. Works with CSC or RCM to identify areas of opportunity and recommend solutions. Completes special assignments and analyzes provider requests. Assists other departments and interacts directly with providers.
• Handles various communication channels with providers, including inbound and outbound provider calls which involve researching, resolving, and documenting issues.
• Analyzes data and determines if CareCentrix claims processing guidelines have been followed correctly by researching plan, eligibility, and patient authorization information.
• Tracks claim detail errors and communicates to up-line management for coaching and training purposes.
• Accurately identifies complaints and escalates accordingly.
• Participates in and contributes to performance improvement activities.
• Participates in special projects and performances other duties as assigned.
High School Diploma/GED or two years of customer service, claims processing, medical terminology, medical services or equivalent experience required. Knowledge of basic spreadsheet / word processing / data entry and basic math skills required. Knowledge of Claims Management and URAC standards preferred.
• Candidate will possess appropriate empathy and excellent communication (verbal/written), organizational and interpersonal skills.
• Manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking.
• This position requires excellent communication, customer service and problem solving skills, as well as the ability to effectively interact with all levels of management and a highly diverse clientele.
• Must have strong organizational skills and be able to effectively manage time and prioritize tasks.
• Must be able to problem solve difficult situations with internal and external customers, and with process and/or system issues.
• Must have strong organizational skills and be able to manage and prioritize tasks in a timely manner.
• Must have the ability to visualize, listen and resolve customer inquiries, while demonstrating a positive persona of the Company.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.