Job Description:

Responsibilities:

• Consult and confer with medical directors and other clinical staff to ensure the appropriate decision has been made and the approved outcomes are implemented.

• Review, analyze and make determinations on provider requests for increased payments related to coding and/or bundling issues.

• Communicate findings of analysis and documentation to appropriate committee, benefit administrators and leadership, as necessary.
  Initiate claim adjustments on individual cases when necessary and follow and track until completion.

• Provide written documentation of case determinations to appellants and/or all involved parties (including but not limited to physicians, attorneys, senators/legislators, employer groups, etc.) in a timely manner as required by regulatory mandates and legislation.

• Identify trends and high-risk issues to mitigate risk of potential legal actions and/or NCOI focused audits and penalties. Communicate findings to the Legal department, Corporate Communications, Special Investigations, and Healthcare Senior Management. Make recommendations to address future exposure.

• Audit appeal and grievance files as required by Federal and/or State regulatory agencies and provide feedback, education and training to individual employees to ensure compliance with mandates.

• Audit and oversight of entities where delegation of member and provider appeals exists.
  Identify and take corrective action on appeals or grievances that result from noncompliance of contract provisions, appeal or grievance guidelines, provider contract violations and/or medical policies.

• Stays current with press releases, emails, and other forms of communications relaying initiatives, contracting issues, as well as Plan wide concerns.

• Demonstrates high degree of appropriate knowledge of all areas of the plan.

• Identify and create action plans to educate internal departments on benefit misinterpretation and/or claim payment system errors.

• Answer member/provider questions via incoming telephone calls in a professional quality driven manner.

• May handle complaints/grievances as defined by the federal government.

Hiring Requirements:

• Associate's degree and 6 months to 1-year claims, customer service, medical office (billing, authorizations and/or patient accounting etc.), health insurance or coding experience 

• If no degree, High School Diploma and 1-3 years, customer service, medical office (billing, authorizations and/or patient accounting etc.), health insurance or coding experience 6 months experience in claims, Healthcare Management and Operations, and/or customer service.

Nice to have: Facets experience - Medicare CTM Experience - or Appeals and grievance experience - someone familiar with claims and healthcare, troubleshooting minor computer issues.

About ASK: ASK Consulting is an award-winning technology and professional services recruiting firm servicing Fortune 500 organizations nationally. With 5 nationwide offices, two global delivery centers, and employees in 42 states-ASK Consulting connects people with amazing opportunities

ASK Consulting is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all associates.