Job Summary

Reviews and resolves complex claims issues, using established state and federal guidelines, departmental policies and procedures to ensure that work is performed accurately and delivered to meet set objectives. Acts as a liaison between the provider and other Health Plan departments and facilitates the exchange of information between the grievances, claims processing and provider relations systems. Follows up with providers, internal and external vendors to ensure resolution is communicated to impacted parties.

Job Duties

• Acts as the technical claims expert, following state and federal guidelines and provider contracts.
• Educates contracted and non-contracted providers regarding appropriate claims submission requirements, coding updates, electronic claims transactions and electronic fund transfer and available resources such as provider manuals, websites, fee schedules, etc.
• Provides on-site professional guidance as needed to facilitate issue resolution.
• Evaluates and resolves complex claim and provider billing issues in a timely manner and according to set standards.
• Coordinates with the provider, as needed, in alignment with the Account Management team, on claims processing issues and provides follow-up to all impacted parties.
• Works with the customer service team to ensure accurate interpretation of billing guidelines, member benefits, contract terms, exclusions and limitations; escalates as necessary.
• Interfaces with the call center to compile, analyze and disseminate information from provider calls.
• Provides feedback to the configuration team to ensure payment terms are set-up correctly.
• Assists with completion of claims audits to ensure accurate payments to providers.
• Responds to provider inquiries regarding claims payments.
• Communicates with providers to gain feedback regarding the extent to which providers are informed about appropriate claims submission practices.
• Provides information and facilitates and coordinates appropriate resolution of issues and complaints.
• Documents inquires, complaints and other data in all applicable systems in an accurate, clear and timely manner.
• Identifies trends and develops ways to streamline and simplify internal processes as necessary to reduce turnaround times and improve data quality and provider satisfaction.
• Initiates process improvement projects resulting from operational concerns.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

Position Details

If a suitably experienced candidate cannot be found, applicants who meet the basic qualifications but possess fewer years of experience will be considered for hire at a lower level. Salary would commensurate with experience.

PREFERRED EXPERIENCE:

Facets claims and working with provider offices

Internet requirements:

Employee required to have/supply: Cable modem, (high speed, only - No DSL or Wireless Cellular Service or Satellite Service) The minimum requirement is:

• 5 MBPS UP
• 20 Mbps DOWN
• <75 ms Ping Required
• <30ms Gitter Required

• Computer must be connected to the internet via Ethernet cable; wifi is not permitted unless a Virtual Private Network (VPN) is used for the wifi connection

Education

High School Diploma or Equivalent (GED)- (Required)

Experience

Minimum of 6 years-Relevant experience* (Required)

Certification(s) and License(s)

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.