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Claims Representative II
Ref No.: 18-11900
Location: Oak Brook, Illinois
Start Date / End Date: 10/01/2018 to 03/31/2019
Job Description: Summary: Resolves Provider Reconsideration Requests (PRR) from providers relating to claims payment and requests for claim adjustments. Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error. Identifies potential Provider problems through a proactive approach in which data is mined and trended to identify and prevent provider problem areas. Uses of a variety of references, to research and prepare healthcare provider information to be loaded into and maintained on a database. Uses Windows based software to record or verify a variety of standard and complex source data. Some data entry required. Interfaces with other departments in regards to questions about provider configuration. Essential Functions: ¿ Handles written response to incoming reconsideration requests from providers and outside agencies. ¿ Enters provider demographic and contract affiliation information into the health plan system. ¿ Researches and documents inquiries and proactive research in a thorough, professional and expedient manner. ¿ Completes appropriate documentation for tracking/trending data. ¿ Composes correspondence to reflect accurate resolution information in a clear, concise, grammatically correct format. ¿ Maintains tracking system of correspondence and outcomes of request; maintain organized and accurate files. ¿ Monitors each request to ensure all internal and regulatory timelines are met. ¿ Communicates with Provider Service Representatives regarding relevant provider issues. Knowledge/Skills/Abilities: ¿ Knowledge of medical terminology, CMS claims coding guidelines, and Provider Contracts ¿ Comprehensive knowledge of healthcare customer service ¿ Good MS Office knowledge (Outlook, Word, and Excel) ¿ Ability to type 40 WPM ¿ Strong organizational skills ¿ Excellent problem-solving skills ¿ Ability to work in multi-disciplinary teams and the ability to perform independently while handling multiple projects simultaneously ¿ Excellent verbal and written communication skills ¿ Ability to abide by Client¿s policies ¿ Ability to maintain attendance to support required quality and quantity of work ¿ Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) ¿ Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers Required Education: High School Diploma or equivalent GED Required Experience: 2-4 years experience in a managed care setting. CPT and ICD-9 coding, data entry, and 10-Key experience.
Comments for Suppliers: Work on IL Provider Appeals and Dispute backlog