2 jobs found

Summary Description Encounters data is essential for monitoring and measuring managed care quality, finance, utilization and compliancy with state and contractual requirements. It is a critical source of information for rate setting, HEDIS score and risk adjustment. The Encounter team is responsible for receiving, capturing, validating, tracking submission, reconciling response files and error correcting rejections of encounters data rendered to members. The Claims Processor will be supporting with reviewing, logging, batching, creating and issuing Claims Acknowledgement letters and Return to Provider letters, processing of claims, along with handling providers inquiry to claims payment. Key Tasks and Responsibilities • Review for accuracy and completeness of inbound claims. • Verify member eligibility. • Validate calculation of the reimbursable amount. • Create an Excel spreadsheet with necessary data items that serves as upload for payment from Finance. • Update Itineris with necessary member, rates and provider data. • Approve claims that are complete, eligible and accurate data elements. • Reject claims that are incomplete, inconsistent data elements or duplicates. • Print and mail Claims Acknowledgement letter to providers. • Print and mail return letter to providers with rejection reason. • Manage and respond to provider inquiries regarding claims status and payment by researching system for claims history. • Identify issues, report to Director and propose solution. Education & Training • Required: High School Diploma or GED • Preferred: Medical claims processing and billing Knowledge and Experience • Knowledge of CMS 1500 forms and fields. • Knowledge of required transportation HCPCS codes, modifiers, provider Medicaid ID, TIN and NPI. • Knowledge of state Medicare and Medicaid program guidelines and requirements. • Strong understand of Itineris and Excel software. • Strong data entry skills. • Excellent customer Service. Core Competencies • Strong organizational skills • Ability to communicate efficiently with multiple areas of the organization • Strong written and verbal communication skills • Track claims, payment and rejections • Ability to multi-task with frequent interruptions • Exceptional attention to detail and accuracy • identify missing or invalid claims data • Abide to deadlines Working Conditions • This is a Full time hourly position. • Benefits after 60 days include medical, dental, vision, voluntary life and 401(k). • No travel is required. Physical Requirements  • This position requires working on a sitting position working on a computer and operating a keyboard and a mouse as well as other office equipment like phones and printers and filing documents.

Summary Description The Care Center Manager is responsible for the execution of various call center strategies which is inclusive of meeting all service level standards for the lines of business supported within the Care Center. In addition, this role must conduct regular monitoring of site performance through available standards and metrics ensuring that the company goals and objectives are achieved. The emphasis for this role is to ensure that our products and services are compelling, highly desirable, service oriented and best in class. This role will be expected to fulfill these objectives through a variety of deliverables, including but not limited to; inspiring, leading and growing the talent of front-line supervisors. This role demands someone that thinks critically about maximizing the business value of our service offerings. Key Tasks and Responsibilities Ensure all employees always uphold the company core values • Present yourself in a professional, organized manner that conveys confidence and willingness to be approached • Oversight of the overall call center service levels to the service level agreements • Ensure the Care Center culture is inclusive, engaging and rewarding • Review and access responses proposed corrective measures, and investigation reports regarding client feedback • Evaluates various processes, policies and procedures of the group for further improvements (e.g., training period, manpower planning, system improvement initiatives, etc.) • Conduct regular process reviews of operations in order to assess its strengths and identify areas for improvements • Ensure received requests, specifications, and directives from client representatives are properly addressed and resolved • Conducts regular interface with clients to ensure that their needs and requirements are met • Coordinates HR related concerns such as Disciplinary actions, HR forms, Disputes, etc • Collaborate cross-functionally with other departments/leaders to ensure call center practices are in line with the expectations of the business • Assist with taking and resolving escalated calls • Provide feedback and mentoring to staff Education & Training Trained in PHI, HIPAA, and Fraud, Waste & Abuse. Knowledge and Experience • Proficient in oral and written communication skills • Outstanding and proven Customer Service skills • Must be flexible, able to multi-task and have the capacity to work in a fast-paced working environment • Strong Comprehension of Internal Reservation process • Effective Training experience preferred • The position may require you to sit for extended periods of time • The position may require you to travel to attend training seminars, collaborate with other offices or to assist in new markets Core Competencies Possess effective communication skills, planning and organizing ability, problem analysis, problem solving, flexibility, the ability to delegate, stress tolerance, initiative, negotiation skills, persuasiveness and attention to detail. Working Conditions Must be able to work during any hours of Care Center Operations Secure Transportation is an EEO/AAP Employer.