Provider Inquiry Manager

Company : Doctors Healthcare Plans

Job Description - Provider Inquiry Manager

The Provider Inquiry Manager provides leadership and oversight of claim disputes. The position involves researching and investigating claim disputes, authorizing adjustments, and referring claim disputes for further review as necessary.

Key Responsibilities:

Lead and oversee all claim disputes functions utilizing claim disputes system, external platforms and appropriate state and federal guidelines
Ensure timely, efficient, accurate and compliant resolution of claim disputes
Research member eligibility, correct application of benefits, prior authorizations, provider contracts, fee-schedules, claim rules and system configurations
Maintain and enhance claim disputes system
Develop, track, and analyze claim dispute reports, including but not limited to inventory, processing times, data integrity, financial impact, etc.
Lead special claim dispute projects
Review and audit high-dollar and complex claim disputes
Identify opportunities to improve claims processing, and reduce risk and inefficiency
Analyze claim processing gaps, communicate with stakeholders and recommend process improvements leveraging analytics, automation, and AI-powered tools
Develop and refine claim dispute manual, SOP, workflows and policies and procedures
Provide on-going training and coaching to staff
Develop and mentor a high-performing, accountable team, fostering a culture of professional growth, operational excellence and provider-centered service
Work closely with the Provider Relations team to ensure claim dispute escalations are handled timely and with a high level of satisfaction
Collaborate with other departments to integrate best practices and enhance overall operational solutions
Meet performance metrics and goals established for the position
Performs additional duties and responsibilities as assigned by management

Qualifications:

Minimum of 10 years of healthcare operations or Medicare Advantage experience; strong knowledge of Medicare Advantage, CMS and AHCA regulatory requirements
Expertise in professional and facility claims disputes and/or appeals, claims processing, provider compensation, benefits, coding and medical terminology
Proven track record in strategic planning, operations and process improvement
Able to thrive in a complex, high-pressure environment
Outstanding organizational and interpersonal, written, and verbal communication skills
Bachelor’s degree in Business, Healthcare Administration, or a related field
High-degree of computer literacy and advanced Excel spreadsheets for operational data analysis and reporting

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

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Provider Inquiry Manager

Job Description - Provider Inquiry Manager

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