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Efficiently and accurately conducts the intake of all incoming documents including but not limited to Member and Provider Appeals, as well as re-routing Grievances, Pharmacy, Claims Correspondence, etc., and related requests. Determines appropriate classification of each request, performs research and accurate data entry, as well as conducts initial processing and assignment of the requests. Performs duties related to root cause analysis of escalated issues involving member and provider Appeals.
Utilizes multiple systems to gather information, conduct research different data sources including Xcelys, WC Toolbox, Application Extender, Emma, Appeals Tracker, assess the situation, and enter data. Needs to access and interpret claim, appeal correspondence and authorization data.
Perform detailed root cause analysis to determine core issue related to member and/or provider complaint, error or inquiry.
Conducts intake and appropriate classification of Appeals, Grievances, Pharmacy, and Claims Correspondence etc. requests and makes accurate judgment on appeal, grievance, claim disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the enterprise.
Electronically enters claim detail information in organization applications including Sidewinder, Peradigm, databases or specified work flow tool and documents receipt, disposition and other noteworthy aspects of the cases in the application.
Evaluates data input and output for accuracy and ensures compliance with data integrity and corporate compliance directives.
Completes data entry of all enterprise requests in an environment where compliance and accuracy are critical. Ensures timely processing and review of documentation to meet departmental goals and state specific benchmarks for timeliness.
Performs special duties as assigned.
Additional Responsibilities:Candidate Education:
Required A High School or GED
Required or equivalent work experience
Required 1 year of experience in a Claims, Customer Service, Appeals, Pharmacy, Front End, Configuration or Enrollment, Data Capture role, preferably in a health services environment.
Intermediate Demonstrated written communication skills
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Ability to work as part of a team
Intermediate Other Ability to review correspondence and system data to determine appropriate handling consistent with applicable policies and procedures.
Licenses and Certifications: A license in one of the following is required: Technical Skills:
Required Beginner Microsoft Word
Required Beginner Microsoft Excel
Required Beginner Microsoft Outlook
Required Beginner Other Ability to work across multiple computer programs to process a single request