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Medical Claims Specialist

2 months ago

Albuquerque, New Mexico, United States Innova Solutions Full time
Job Summary

We are seeking a highly skilled Medical Claims Specialist to join our team at Innova Solutions. As a Medical Claims Specialist, you will play a critical role in ensuring the smooth operation of our healthcare networks and providing exceptional service to our clients.

Key Responsibilities
  • Provide information and assistance to resolve problems experienced by healthcare providers in their contractual relationships with us, including claims, pricing, and contracts.
  • Assure both parties understand the mechanics of our relationship and that our networks are working well for all involved.
  • Record activities in the required format and keep management advised of activities and needs.
  • Assist in providing training and continuing policy education on all facets of operations to provider staff and others as needed.
  • Conduct provider servicing and assist in the development and distribution of training materials, etc.
  • Submit reports on service and recruiting activities and other items as required by management.
  • Respond to fee requests from providers.
  • Provide ongoing development of database, reports, and statistical analyses of managed care networks.
  • Assist with the coordination and resolution of systemic problems and claim issues.
  • Identify problems, research the impact and origin for resolution, and report to management.
  • Assist with the review of provider directories for the managed care networks.
  • Develop and maintain a good working relationship with Core Services, Local Medical Directors, and other internal departments.
  • Coordinate with various departments as required for the recruitment, servicing, and retention of contracted providers.
  • Establish working relationships with key facilities, physician groups, practice managers, IPAs, PHOs, and other essential contacts.
  • Serve as a liaison between facilities or provider office staff and various internal departments.
  • Maintain a high level of expertise in pricing arrangements, contract requirements, benefits, membership, claims processing, utilization review, etc.
  • Process provider change forms and maintain a tickler system.
  • Prepare monthly reports and update provider databases as necessary.
  • Assist with routine and special reporting requirements.
  • Prepare and mail provider orientation packets, provider manuals, and application packets.
  • Communicate and interact effectively and professionally with coworkers, management, customers, etc.
  • Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies, and other applicable corporate and departmental policies.
  • Maintain complete confidentiality of company business.
  • Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
Requirements
  • Bachelor's Degree or 4 years of work experience in the healthcare/insurance industry.
  • 3 years of experience in Network Management, Credentialing, and/or Customer Service.
  • Understanding of healthcare contracts, applications, and products.
  • Working knowledge of claims processing systems.
  • 3 years of experience utilizing a PC.
  • Verbal and written communication skills.
  • Teamwork and problem-solving skills.
  • Analytical and organizational skills.
  • Organizational skills and experience meeting deadlines and working well under pressure.
  • Familiarity with provider reimbursement methods.
Preferred Requirements
  • Knowledge of healthcare policies, products, and procedures.