Regular
Exempt
GENERAL DESCRIPTION:
Responsible for developing, promoting, and maintaining a healthy business relationship with providers taking part in our network, guaranteeing satisfaction, retention, and new referrals of prospects. Serves as the main liaison between the company and the provider to address, direct, and solve service situations, situations related to complaints, claims, and operational situations that affect them, among others.
ESSENTIAL FUNCTIONS:
Serves as the primary contact for specialists, subspecialists, Primary Care Providers (PCPs), dentists, and health allies to address, direct, and solve service situations, keeping the quality standards of service and guaranteeing that they are resolved within the established time. Guides the provider on the contractual and service agreements between the company and the provider.
Verifies and ensures providers' settings are correct on the various Power Management Health System (PMHS) screens.
Trains provider and medical office staff on how to access the Provinet tool, its capabilities, and its functionality, such as verifying eligibility, accessing claims, payment histories, and circular letters, among others.
Manages, directs, and/or solves situations that require intervention related to providers, such as investigation of complaints and/or situations of improper billing, overcharging of deductibles, and so on, that result in a breach of contract with regulatory agencies, such as Health Insurance Administration (ASES), Office of the Patient Advocate (OPP), Centers for Medicare and Medicaid Services (CMS), among others.
Identifies the root cause of recurring system problems, situations, and/or complaints submitted by the provider. Consults with the Medical Policy and Clinical Review unit to guide the provider on how to bill the appropriate codes according to their specialty and appropriate practices from the provider contract.
Prepares, documents, and maintains a record of the situations reported by the providers in the established tool and guarantees they have been solved.
Reviews the claims adjudication process concerning payment explanation and determines if they are adjudicated correctly in the cases submitted by the provider. Establishes work plans with providers on reconciliations of their accounts and outstanding balances for closing payment cycles
Participates in meetings with visiting providers, as requested. Prepares, manages, and follows up on exception cases presented to the Payment Policy Committee.
Recommends improvements for building, maintaining, and strengthening provider relationships.
Participates in the coordination of service quality monitoring programs, as well as initiatives and educational activities aimed at strengthening relationships with providers and keeping them informed of any changes.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS:
Education and Experience: Bachelor's degree, preferably in Business Administration, Health Services Administration, or other health-related fields. At least three (3) years of experience performing functions related to provider service, including, but not limited to, claims processing, analysis/investigation, drafting of low-complexity reports, and establishment of work plans, preferably in the Healthcare Industry.
"Proven experience may be replaced by previously established requirements."
Certifications/Licenses: N/A
Other: Knowledge of Medical Billing. Extensive knowledge of provider database systems (i.e., MHS, among others). Availability to work extended hours, weekends, and holidays, according to the business needs and the requirements of regulatory agencies applicable to the industry.
Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)
"Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento"
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