Position Purpose: Manage the Claims Liaison and Provider Data Management department and staff. Function in the capacity of the claims payment expert for the Plan and as a liaison between the plan, claims, Medical Management Department, Corporate Finance and providers to effectively identify and resolve claims issues. Partner with others in Provider Services/Relations who identify and resolve claims issues, and provide instruction to providers’ billing staff and services regarding claims submission policies and procedures to insure prompt and accurate claims adjudication.
- Manage the Claims Liaison department and staff and provide expertise to staff to assist in claims issue resolution.
- Prioritize work volumes on a daily basis.
- Provide Health Plan management with all necessary data to allow for expedient resolution of claims issues & support Health Plan management at all times.
- Coordinate documentation, tracking and resolution of all plan providers’ billing and payment issues.
- Provide expertise and research verbal and written providers’ claims inquiries from plan and corporate staff.
- Provide expertise to Provider Services/Relations in the identification of Medical Management authorization issues and trends.
- Utilizing knowledge of provider billing and claims processing, directs Provider Services/Relations with the claims reprocessing notification.
- Track trends in claims processing issues and assist Claims Department in identifying and quantifying issues along with reviewing Claims Department work
Education/Experience: Bachelor’s degree in related field or equivalent experience. 7+ years of claims processing/researching or provider contract experience in a managed care environment. Management experience strongly preferred.