Provider Claims Service Specialist
SUMMARY:
Investigates and resolves processing issues for BlueCard Host Program claims that are identified through direct and indirect inquiries received from IBC Host providers.
DUTIES AND RESPONSIBILITIES:
• Provides prompt, professional, courteous and quality service to contracting facility providers within IBC's five county and contiguous service area.
• Achieves and maintains the knowledge and skill level required to provide accurate information and superior support in response to provider inquiries received via correspondence, telephone and/or during facility site visits.
Identifies and documents the root cause of inquires and initiates appropriate action for resolution, up to and including claim and/or adjustment processing.
Provides response to general questions within 48 hours of initial inquiry Provides daily feedback, status updates and targeted resolution date for more complex issues.
Prepares and submits provider status reports to hospitals and/or internal departments in support of inquiry related projects, including analysis, update and resolution.
• Effectively interfaces with IBC Host providers, IBC operational divisions, (i.e., Hospital Services, Finance, Claims Operation Reporting and Provider Services) and with other Blue Home Plans in the resolution of Host provider service issues.
Demonstrates and conveys a clear understanding of the Host BlueCard process. Educates providers regarding the BlueCard Program.
Coordinates with other Blue Home Plans to expedite problem resolution
• Employs appropriate processes and procedures to support inquiry resolution and achievement of departmental goals:
Creates and updates Host Profile for assigned AR facility
Conducts routine meetings with providers to review issues/concerns Documents provider issues
Maintains an accurate and current inventory list of problematic claim submissions Attends internal and external meetings relating to assigned AR facility
Alerts department management of potential problems Coordinates and supports activities for Host Escalation
Works closely with management team to assist with resolution of provider related issue.
EDUCATION AND EXPERIENCE:
• High School Diploma
• Two to four years work experience performing various tasks related to Member Service functions, i.e., telephone servicing and claims processing.
• Knowledge of claims processing systems (membership, providers and claims adjustments)
• Experience working with providers and members.
• Ability to accurately perform research analyzes, determine root cause and determine appropriate action.
• Thorough understanding of medical terminology, procedure codes and diagnostics.
• Strong oral and written communication skills necessary.
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.
Inclusion and Belonging
At AmeriHealth, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
About Our Company
Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.
At AmeriHealth, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!
Equal Employment Opportunity
AmeriHealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Agency Disclaimer
All resumes submitted directly to an AmeriHealth employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of AmeriHealth and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by AmeriHealth or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.