The main goal of the position is to reduce denials and rejections through provider awareness and education, system remediation and enhancement, and through focused analysis on the drivers of these denials and rejections. This position receives/responds to provider claims issues, escalations, and complaints. Researches information by reviewing plan, eligibility, patient notes, and authorizations to determine appropriate resolution. Works with CSC, Network Management and/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. Proactively outreaches to providers to educate on opportunities and trends identified during claims analysis. Subject matter experts responsible for facilitating decisions regarding best practices and subsequent effectiveness of process changes which will ultimately support smooth and effective business operations.
• Handle various provider claims escalations, complaints, and special projects which include researching, resolving, and documenting provider claims issues.
• Proactive outreach to providers to educate after analyzing data to identify trends resulting in claims issues.
• Tracks CSC errors and communicates to up-line management for coaching and training purposes.
• Track and summarize claims reviews for Executive review.
• SME support on claims triage with Providers Services/RCM and Network Management to ensure remediation and minimize future issues.
• SME support for scripting and educating CST on new releases, projects/initiatives, system issues, new implementations, and process changes.
• Analyzes data and determines if CareCentrix guidelines have been followed by CSC when researching plan, eligibility, and patient information.
• Participates in and contributes to performance improvement activities.
• Participates in special projects and performs other duties as assigned.
Bachelor’s Degree preferred with 3+ years of related experience .
Effective analytical and communication skills required. Experience in the managed healthcare service industry, withknowledge of the insurance/managed care/reimbursement and customer service industry is preferred. MS Office proficiency including: Word, Excel, PowerPoint, and Outlook.
• Candidate must possess excellent communication (verbal/written), problem resolution, organizational and interpersonal skills.
• Ability to function in a fast paced environment, the capability to work in a highly efficient manner, the proficiency to multi-task, and the ability to prioritize workloads is critical.
• Time management skills to work on a variety of projects under specific time restraints
• Successfully fulfills work assignments with a high level of accuracy
• Must have the ability to interact with all levels (from associates to senior executives).
• Must be detail oriented, be responsive, and demonstrate independent thought, good judgment and critical thinking.
• Must be able to problem solve difficult situations with internal and external customers, and with process and/or system issues.
• 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.