Claims Resolution Coordinator

To research and resolve complex claims issues which cross interdepartmental lines and communicate the outcome to providers and affected Partnership managers. Develops and maintains provider training materials for all lines of business. Conducts provider trainings across Partnership departmental lines in group or individual provider settings. 

• Answers customer service lines as necessary and responds to provider inquiries either by phone, email, or in person regarding claims related questions.
• Reviews, researches, and works with various departments to resolve complex provider inquiries, appeals, and grievances.
• Acts as a resource and provides support to customer service staff, as well as Provider Relations staff for complex Provider questions regarding claims and payments.
• Coordinates with Claims, Member Services, Health Services departments, the development, maintenance, and training of ongoing educational materials and tips for inclusion on the PHC website. Incorporates educational materials into the PR Manual and update on a quarterly basis.
• Processes CIF's and adjustments as needed.
• Writes and runs reports in Business Objects to obtain needed claim data.
• Tracks and analyzes provider trends with denials and CIF's to provide support to providers with an opportunity to improve. Distributes provider scorecards.
• Tracks  complaints, appeals, and grievances by program. Reports activities on a quarterly basis to IQI, PHC Compliance Coordinator, and Claims Director.
• Presents findings and recommendations for ongoing, long term resolutions to issues. Identifies items to address the “provider hassle factor.”
• Acts as liaison and meets with designated staff from Claims, Health Services, Member Services, and QI departments to identify ongoing provider issues.
• Coordinates system issues with Claims Configuration staff, IT staff, and PR Lead Project Specialist/Auditor. Leads or participates in special projects as needed.
• Other duties as assigned

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$ 37.22 - $ 46.53

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.