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Cust Provider Resolution Rep

Allenton, Wisconsin
20 Sep 2022

Major Responsibilities:

  • Eligibility, Benefits and General Duties
    •     1)Using excellent interpersonal skills deescalate callers that are distraught or upset due to real or perceived difficulties they have encountered. Make logical and accurate decisions often while facing stressful situations (applies to all categories).
    •     2)Frame and communicate outcomes of investigation in an optimal manner leaving callers with a positive view of Advocate even if resolution is not what they originally anticipated (applies to all categories).
    •     3)Service will be provided to internal and external customers for AHPO and AHC by having a rapid response to inquiries, efficient routing of requests to other AHPO departments when needed, and responding to callers in a customer friendly, focused environment (applies to all categories).
    •     4)Assists in retrieving and responding to all voicemail messages within one (1) business day, and in incoming calls (applies to all categories).
    •     5)Researches eligibility disputes; contacts managed care organizations, employers, updates IDX System, works closely with Eligibility Department if retro capitation situations occur.
    •     6)Responds to benefit plan concerns and educates callers on interpretation of the benefits. Reports copay and other benefit loading errors and delays when they are identified.
    •     7)Documents all complaints/grievances and refers to appropriate department when required (QI, systems, UM, Provider Relations, Service Enhancements, etc).
    •     8)Acts as a liaison between various AHPO departments to identify system related capitation, referral and eligibility problems and works with various departments to ensure proper resolution.
    •     9)Assists members in primary care selection and primary care changes. Documents and updates IDX System.
    •     10)Complete documentation of telephone inquiries utilizing the Customer Service Module (Applies to all areas).
  • Provider Education and Assistance
    •     1)Facilitates changes to ensure the accuracy of all operation issues related to providers, i.e., dictionary updates, provider listings, referral processing, claims payment and fee schedules.
    •     2)Reviews causes for billing errors and assists providers in making appropriate corrections. Reports potential issues with Ingenix and IDX.
    •     3)Reviews risk grids and educates providers, MCO representatives and others regarding payment responsibilities. Reports potential system errors via CCIRP.
    •     4)Assist members and physician office staff in checking referral status in computer. Researches referrals for members.
    •     5)Reviews, obtains and verifies accurate information on dictionary vendor request forms for loading or changing of new/existing contracted providers.
  • Claims and Referral Issues
    •     1)Assures that denied claims and referrals are rectified in a timely manner.
    •     2)Adjust and make final payment or denial determination for previously processed claims per AHPO guidelines.
    •     3)Identify claims that require coordination of benefits (COB) and apply claim adjudication rules per AHPO guidelines.
    •     4)Responsible for initiating calls to HMOs, primary care physician, PHO or member to resolve any outstanding issues.
    •     5)Intervenes to diffuse member calls/accounts in collection. Contacts agencies to make adjustments and payment arrangements from AHPO or MCO when applicable.
    •     6)Respond to insurance inquiries, process claims in IDX in a timely manner to resolve issues. Problems solves system and manual adjudication errors. Must be highly skilled in claim processing to correct and report system and associate errors.
    •     7)Perform back-out activities on previously processed claims when needed per AHPO guidelines.
    •     8)Enforce new claim policies and procedures relating to new procedures, benefits and reimbursement rates per PHO. (grids issues, memos from PHO's HMO's, etc.)
  • Contract and MCO Contract Interpretation
    •     1)Responsible for review and application of individual; HMO contract benefit provisions and for identifying and reporting any discrepancies.
    •     2)Apply special rules and/or guidelines as determined by the medical director or senior management.
    •     3)Reviews contract terms and educates providers and their staff regarding compensatory issues related to the contract. Reports potential system errors via CCIRP
    •     4)Responsible for review and application of individual; HMO contract benefit provisions and for identifying and reporting any discrepancies.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

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  • Job Reference: 717168699-2
  • Date Posted: 20 September 2022
  • Recruiter: Advocate Aurora Health
  • Location: Allenton, Wisconsin
  • Salary: On Application