Financial Representative 2

Description of Work/Duties:

Based on the Governor’s recent Executive Order prioritizing work experience and skills over educational attainment - Have knowledge of Medical Assistance, health care insurance, health care provider participation/enrollment, provider or pharmacy service authorization and the medical claims and billing process. Experience in customer service and/or call center experience is a plus. Possess a high school diploma or GED. A bachelor’s degree in accounting, business, math or a human services field will be considered in lieu of experience.

Consultant will work with the Department of Human Services, Office of Medical Assistance Programs (Department). This is a professional level position responsible for various operational aspects of the Fee-for-Service Medical Assistance program. This involves a wide range of tasks related to health care claims and billing, resolution of health care provide financial accounts, health care provider enrollment, and prior authorization for health care and pharmacy services. Consultant will perform a wide range of duties depending on the Division within the Bureau the position is assigned:

• Be available as a consultant on average 37.5 hours per week;

• Possess basic computer skills, including familiarity with Microsoft Office programs.

• For the Division of Operations, the Financial Representative 2 consultant duties include:

· This position is responsible for oversight and assistance on the Provider Service Call Center including assisting staff member in the chat with questions.

· Must pull monthly calls and score staff calls regarding accuracy and content.

· Take over elevated supervisor calls.

· Make outreach calls to providers to assist with higher level issues.

· Monitor the call center platform for calls in que. During higher call volumes assist taking calls on the line.

· Monitor and respond to resource account regarding billing issues.

· Train new hires and retrain all staff on reoccurring issues and upcoming initiatives.

· Monitor daily calls for short calls and the reason for the short call.

· Schedule one on one sessions with staff and retrain when areas are lacking.

· Run daily reports.

· Organize and present material for monthly in office staff meetings.

· Analyze billing inquiries to Medical Assistance to determine if the claim processed correctly and paid the correct amount. If the claim denied, determine the cause of the denial and explain the reason for the denial based upon their knowledge of PA regulations and MA billing guidelines.

· Evaluate the provider’s Remittance Advice to explain payments and assist with billing and payment issues. This includes explaining any payment offsets from the Medical Assistance program and the reason.

· Communicate with the Bureau of Data and Claims Management, the Office of Legal Counsel or the Comptroller regarding delinquent accounts, payment offsets or gross adjustments.

· Assist in the Gross Adjustments process and issuing payments or issuing credits

· Refund of Expenditures and coordinate refund efforts with the Comptroller’s Office.

· Review, analyze, and evaluate provider data and information received with the checks and evaluates if gross adjustments may be granted based on Medical Assistance regulations, policies, or objectives. Enter gross adjustments for approval by the Division Director.

· Prepare materials necessary for the disposition of all checks received from providers, insurance companies, recipients, and attorneys. Responsible for the review and analysis of Medical Assistance Program regulations, and Federal Regulations and policies as they relate to enrollment by maintaining a system for evaluation, interpretation and implementation to ensure program area compliance.

· Generating communications to providers regarding claims and billing issues.

· Explaining and assisting providers on how to bill their claims and assisting recipients with understanding their benefit packages and locating providers.

· Evaluate the billed information to determine if the proper procedure codes and modifiers were billed correctly. Determine and advise if a health care procedure code requires a prior authorization.

· Analyze claims to see if they meet 180-day exception criteria.

· Evaluate the recipient’s assigned eligibility to see what services they are eligible for under the Medical Assistance program.

· Assist recipients with reimbursement requests by educating providers on their contractual responsibilities under the MA program.

· Review previously billed services for potential duplicate billing.

· Provide dental history research to avoid duplicate billing or denied claims from occurring.

· Determine the need to refer issues to external agencies or to the Bureau of Program Integrity for review.

· Answer questions from the provider and recipient community on various topics.

· Participate in meetings, receive updates on system changes or new policies.

• For the Division of Provider Enrollment, the Financial Representative 2 consultant duties include:

· Field inquiries to answer a full spectrum of provider participation questions including requirements for enrollment in the Medical Assistance program based on provider types and specialties, conditions of participation and the enrollment process.

· Screen and process provider enrollment applications,

· Inform provider applicants of error, omissions and corrections needed to process MA enrollment applications and process notices to providers.

· Conduct required background clearance checks.

· Verify information captured in MA enrollment application is present in provider file in the Medical Assistance Information System.

· Responsible for the timeliness and accuracy of information posted to the Department's website relating to provider enrollment.

· Attends and conducts workgroups responsible for developing, recommending and implementing changes to policies and procedures that affect the provider enrollment process. Implement executive decisions.

· Participate in team meetings, receive updates on system changes or new policies.

· Perform work on provider Medical Assistance error reports as assigned.

• For Division of Clinical Review, the Financial Representative 2 consultant duties include:

· Field inquiries and coordinate with designated clinical staff for their resolution.

· Schedule calls and teleconferences for Medical Directors, compile information to be included in the teleconference packets and forward to the appropriate Medical Director for their review and use.

· Access Medical Assistance provider-submitted prior authorization requests and forward to designated nurse reviewers for clinical determinations.

· Provide support related to the Medical Assistance provider appeals section, as assigned.

· Provides mail processing support as assigned.

• For Division of Pharmacy, the Financial Representative 2 consultant duties include:

· Assume primary responsibility for designated operational area within Pharmacy Division

· Assist pharmacists with retrospective drug utilization review cases for inappropriate prescribing and abuse/diversion of controlled substances

· Field questions related to the specialist’s primary area of focus and communicate details to physicians, pharmacists, and Commonwealth staff

· Assist with early refill request reviews

· Coordinate referrals with other Bureaus and Offices within the Commonwealth as needed

· Coordinate with MMIS (Medicaid Management Information System), drug rebate, Statewide PDL(Preferred Drug List), Specialty pharmacy contractors for pharmacy related tasks/functions

· Assist the pharmacy administration in projects related to the Medicaid drug benefit

· Coordinate and lead team meetings and any other committees as needed

· Perform other duties and assignments as directed by the Director/Supervisor

· Assist with call center operations (e.g., phone and fax requests)

· Issue prior authorizations as appropriate through established protocols, policies, and procedures

· Assist in the development of policies and procedures for utilization management initiatives

· Responsible for pharmacy/drug hearings and appeals process and coordination with Bureau of Hearings and Appeals

· Data query and analysis for pharmacy-related requirements

About Us:

TulaRay partners with clients to create staffing solutions that meet unique organizational needs. Our services are designed to reduce administrative burdens, protect your brand, and improve assignment time-to-fill. We believe that mutually successful client relationships are built on lasting quality and exceptional customer service. We pride ourselves on our uncompromising commitment to high-quality emergency management & healthcare personnel, while ensuring that our clients are taken care of with personalized attention. TulaRay manages total compliance and respectfully supports hundreds of professionals and patient-centered programs.

TulaRay is proud to be an affirmative action employer and is committed to providing equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. If you have a disability or special need that requires accommodation, please let us know by visiting our website at tularay.com