Description:
GENERAL SUMMARY
- Leads the monitoring and evaluation efforts during the group/provider set-up, enrollment process and/or claims payment and benefit interpretation according to contractual agreements, and industry standards.
- Monitors tracking of claims payment errors, group/provider set up, enrollment, vendor interface and data transmission processes. Reports and communicates findings to management.
- Responsible for resolving any inaccuracies or deviations identified during the review process. Reviews and resolves group, broker, provider, interdepartmental, vendor and health plan, and/or claims issues or inquiries related to processes according to review guidelines.
- May resolve any inaccuracies or deviations identified during the claims review process and champions process improvement initiatives. Approves and denies reimbursement based upon established review criteria.
- Reviews and resolves provider and member inquiries related to claims processed according to review guidelines of benefit interpretation.
- Designs and implements procedures, at the direction of management, to identify and analyze trends in member complaints, claims, group/provider set-up, enrollment, and claims payment inaccuracies and deviations in policy applications.
- Responsible for training Operations Liaisons to ensure team members are knowledgeable in all technical and business areas. Evaluates team results based upon review criteria.
- Performs other duties as required.
Qualifications:
- Bachelor’s degree or equivalent experience.
- Significant experience (usually 5+ years) in group set up, enrollment, and direct customer service.
- Previous auditing or quality assurance experience preferred.
- Three years of experience with electronic data transmission.
- Strong communication and interpersonal skills.
- Strong analytic and problem solving abilities.
- Knowledge of IDX, Excel and Access preferred.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Louisville, KY, US
Organization: 38500 - Coventry Health & Life-KY
Schedule: Full-time
Job Posting: 2012-11-30 00:00:00.0
Job ID: 1211861
GENERAL SUMMARY
Prior Medical Exeperience Preferred! Hospital Billing experience a plus!
Leads the monitoring and evaluation efforts of claims payment according to provider contracts and/or group/provider set-up, eligibility according to contractual agreement, evidence of coverage, and industry standards. Identifies and analyzes trends in member complaints, group/provider set-up, claims and/or enrollment inaccuracies, and deviations in policy applications including problem resolution. Develops and implements procedures to address and correct any resulting issues. Leads, supports, and assists in training
Operations Liaisons.
ESSENTIAL RESPONSIBILITIES
- Leads the monitoring and evaluation efforts during the group/provider set-up, enrollment process and/or claims payment and benefit interpretation according to contractual agreements, and industry standards.
- Monitors tracking of claims payment errors, group/provider set up, enrollment, vendor interface and data transmission processes. Reports and communicates findings to management.
- Responsible for resolving any inaccuracies or deviations identified during the review process. Reviews and resolves group, broker, provider, interdepartmental, vendor and health plan, and/or claims issues or inquiries related to processes according to review guidelines.
- May resolve any inaccuracies or deviations identified during the claims review process and champions process improvement initiatives. Approves and denies reimbursement based upon established review criteria.
- Reviews and resolves provider and member inquiries related to claims processed according to review guidelines of benefit interpretation.
- Designs and implements procedures, at the direction of management, to identify and analyze trends in member complaints, claims, group/provider set-up, enrollment, and claims payment inaccuracies and deviations in policy applications.
- Responsible for training Operations Liaisons to ensure team members are knowledgeable in all technical and business areas. Evaluates team results based upon review criteria.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Bachelor’s degree or equivalent experience.
- Significant experience (usually 5+ years) in group set up, enrollment, and direct customer service.
- Previous auditing or quality assurance experience preferred.
- Three years of experience with electronic data transmission.
- Strong communication and interpersonal skills.
- Strong analytic and problem solving abilities.
- Knowledge of IDX, Excel and Access preferred.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Louisville, KY, US
Organization: 38500 - Coventry Health & Life-KY
Schedule: Full-time
Job Posting: 2012-11-30 00:00:00.0
Job ID: 1211861