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Investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical records review Serve as a Subject Matter Expert (SME), performing medical record reviews to include quality audits, as well as validation of accuracy and completeness of all coding
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Provide holistic family support to members who may have special needs themselves or may be caring for children or family members with special needs, owning end to end resolution of issues. Serve as an ongoing, point of contact for members, primarily via the phone channel (may also will use email, chat, text), delivering compassionate support to members, creating a memorab
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Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati
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New Client Installation and maintenance determination of structure, data entry into applicable eligibility system. Review rates from the Underwriting, Sales and Implementation departments to ensure accuracy when entering data into required systems. Research and resolution of discrepancies with premium billing invoices, membership enrollment and/or structure set up. Review
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Provide exceptional customer service to all consumers and members of the clinic staff Fills prescription orders and makes them available for verification under direct supervision of the registered pharmacist Orders, receives, and stores incoming pharmacy supplies Receives and processes wholesaler medication orders Verifies medication stock and enters data in computer to m
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Performs all tasks of a Senior Billing Representative or a Senior Customer Service Representative. Based on department needs, monitors one of the following back end operations or functions, front end operations or functions, daily production tracking, and/or patient phones for coverage, quality, reports and call logs. Trains employees and completes other trainings through
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Independently manages daily work to complete patient account follow up activities, including referral to financial counseling and collections. Responsible for maintaining a low receivable by consistent and timely follow up on financial assistance applications. Ensure that all activities related to hospital financial assistance functions meet department requirements, maxim
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Serve as a Subject Matter Expert (SME), performing Advanced Communication Engine (ACE) reviews to include quality audits, as well as validation of accuracy and completeness of all edits within the claim adjudication process Have oversight of audit records and Advanced Communication Engine (ACE) functionality reporting Responsible for guidance related to ACE initiatives to
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Manage overall employee contract loading and use various databases and/or source documents Oversee customer dental and vision plan configuration on multipl e platforms by collaboration with other business partners Research installation issues and develop customer specific resolution Audit contract loads for adherence to quality measures and reporting standards Mentor, coa
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Coordinate and maintain work flows Audit and administer quality control of work completed in the department Perform Senior Billing Representative work duties Handle escalated issues with both internal and external customers, and within the department. Provide training to new and seasoned employees, provide performance input, and assist with disciplinary action. You'll be
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Monitor requests and work proactively to assist Business Development in organizing and completing relevant research or data gathering Update and maintain customer/account information in CRM (Salesforce) in real time Assist with updating and polishing the various existing presentations and proposals that are tailored for prospect / client meetings as needed Prepare and sub
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Performs all supervisory activities such as interviewing, hiring, desk level training for new employees, monitoring employee performance, addressing performance deficits through established disciplinary processes (including and up to termination), preparing and issuing employee performance evaluations, conducting, and participating in team meetings, and coordinating cover
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Receives and documents, telephonic, and electronic requests for referrals from Primary Care Physicians, Specialists and Ancillary providers. Contacts review organizations and insurance companies to obtain prior approval requirements and submit appropriate documentation. Verifies member eligibility and basic benefit coverage levels including obtaining information on coordi
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Participate in process flow analysis and process design along with the team Share best practices and be consultative to clients throughout duration of the project Triage issues reported by the customer Complete and co/implement a configuration workbook Produce a technical specification for custom development and systems integration requirements Participate in training des
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Preparation of outgoing USPS mail, to include printing, inserting and metering mail within time parameters Utilization of various systems for incoming and outgoing FedEx mail and other incoming accountable mail with a tracking number Quality review of output for accuracy, reconciliation, and adherence to postal regulations Open, sort and count incoming mail, including rev
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