This position provides technical expertise through reporting, data research, and analysis for the effective resolution of complex provider inquiries received in their appropriate line(s) of business. Incumbent is responsible for maintaining a comprehensive knowledge of BCBST/VSHP processes that impact the provider community.
Job Duties & Responsibilities
Work within FACETS and other software products to review necessary claims configuration and adjudication.
Interface with other corporate lines of business and research to find root cause and resolution to provider issues (could be routed from the Provider Networks Representatives, Managers, and Regional Directors).
Receives inquiries directly from providers via telephone, email, or provider visits and works to find root cause and resolution.
Serves as subject matter expert on the authorization process and answers provider inquiries regarding this process. Works with provider to resolve authorization issues
Recognize global provider issues and trends as outlined in the escalation procedure. Report those using escalation methods
May travel for visits to provider and/or regional offices may be required. Incumbent may need to explain root cause analysis and resolution and on and off site, utilizing provider’s contract and billing guidelines. May provide educational material.
Other projects, duties, or responsibilities assigned by Management.
Position Specific Information - CHOICES
Maintain in-depth knowledge of provider contracts, billing guidelines, and reimbursement methodologies.
Report claims and call data,
An Associate’s Degree or equivalent health insurance industry experience or equivalent experience is required. Equivalent experience is defined as one year of professional experience for each year of college requested.
Minimum 3 years experience in managed care environment in authorizations or claims processing/adjustments or customer service required.
Provider issue resolution experience preferred
Incumbent must work independently with a minimal amount of supervision.
Must have the ability to problem solve through root cause analysis.
Excellent presentation skills are preferred
Proficient knowledge of PC and Microsoft Office.
Comprehensive knowledge of resources for CPT, HCPCS, ICD, and UB-92 coding is required.
Knowledge of Health Insurance Portability and Accountability Act (HIPAA) standardized claims transaction and code set requirements is preferred.
Must have proven problem solving abilities, strong analytical skills, computer skills, ability to work independently and ability to coordinate department assignments and cross-functional activities.
Must be well organized and have experience in managing multiple assignments with critical deadlines.
Excellent human relations and communications skills (both verbal and written) are essential.
BlueCross BlueShield of Tennessee - 2 years ago
BlueCross BlueShield of Tennessee (BCBST) is the oldest and largest not-for-profit managed care provider in the state of Tennessee....