Performs duties related to root cause analysis of data issues involving member and provider related inquiries for Enrollment, Pharmacy, Claims, Appeals and Correspondence. Efficiently and accurately conducts the intake of all incoming documents including but not limited to Appeals, Grievances, Pharmacy, Claims Correspondence, etc, and related requests resulting from electronically imported, scanned mail, customer service calls, faxes, emails, etc. Determines appropriate classification of each request, performs accurate data entry and conducts initial processing and assignment of the requests.
Reports To: Director, Claims
Position Location: Houston, TX 77081
- Utilizes multiple systems to gather information, conduct research different data sources including data files, peradigm, federal and state systems, 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 workflow 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 initial 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
- Coordinates all activities relative to the introduction of data capture of new documents (i.e., Appeals, Correspondence, Medical Records, etc.) and the revision of existing documents
- Reviews all documents for completeness and ensures appropriate approvals have been obtained prior to data capture and retention. Ensures the maintenance of internal and external controlled documents, approvals and implementation of document changes into Document Control System. Ensures computerization of files that support the documentation system
- Provides Document Control support to Enterprise Intake projects. Also, develops, coordinates, and conducts documentation training. Ensure associates are adequately trained on the various procedures for retention
- Ensures expedited requests are escalated and processed immediately per company, departmental SLA's
- Redirects records as needed and follows up with management as needed to determine appropriate action steps.
- Creates and runs basic reports and queries to produce useable data and distributes as needed
- Serves as a SME in all phases of the Intake process from preloading of cases, case disposition and letter generation
- Develops and presents ideas for performance and process management improvement within the department
- Performs auditing of records
- Performs special duties as assigned
Education: High School Diploma or directly related or equivalent work experience.
Experience: 3 years practical work experience in a Claims, Customer Service, Appeals, Pharmacy, Front End, or Configuration, Enrollment, Data Capture, preferably in a health services environment
Special Skills (e.g. 2nd language):
Ability to review correspondence and system data to determine appropriate handling consistent with applicable P&P
Good verbal and written communication skills
Good interpersonal skills required to work well with others
Ability to work across multiple computer programs to process a single request
Proficient in data entry
Knowledge of Microsoft Office Products including Outlook, Word and Excel.