Assist in monitoring claims inventory and work loads which include but not limited to Provider disputes and appeals assignment, special projects such as Out of Pocket payment adjustments, member services inquiry and requests.
Serve as subject matter expert for all related provider dispute and provider appeals reviews.
Conducts audits and trainings as assigned.
Process provider disputes and provider appeals according to CMS, contractual and departmental guidelines.
Respond to inquiries from providers or other departments on PDR related issues via phone, email or in person.
Work on escalated issues from PDR Analyst that required extensive research and resolution.
Correspond with delegated entity as needed to obtain appropriate records or payment information. Follow through and ensure requested information are obtained.
Produce written correspondence to resolve provider appeals and disputes. Ensure communications contain rationale which supports the determination or resolution of provider appeals or provider disputes.
Prepare appropriate documentation and submit to IRE when provider appeals result in adverse determination and/or untimely. Ensure IRE responses requiring effectuation are processed timely and accurately.
Meets and consistently maintains quality and productivity standards as defined by the Management.
Update and review tracking system to ensure cases are processed timely and appropriate actions are taken.
Identify opportunities for improvement in the PDR function and propose solutions.
Run and monitor various reports which include but not limited to CMS required reporting (Part C, ODAG reports for reconsideration and dismissals, etc.) and other departmental reports.
Provides documentations as requested by other departments such as Compliance and Member Appeals and Grievance.
Collaborates with other departments and outsourcing vendor for the resolutions of provider disputes and provider appeals.
Participate in CMS and other health plan audits related to provider dispute and provider appeals.
Identifies root causes of claims denial or payment variance and escalates to department management as appropriate for training opportunities and corrective action.
Assists in preparing and reviewing cases for regulatory and other health plan audits.
Actively participates in ongoing training to support company and department initiatives.
Supports department initiatives in improving processes and workflow efficiencies.
