Responsibilities
Negotiate and resolve large volume of balance billing inquires, negotiate fees and discounts for members with non-participating providers to reduce out of pocket expenses;
Communicate via telephone and written correspondence with providers, members, attorneys, or collection agencies to resolve balance billing/fee negotiation inquiries to completion; handle large call volume in reference to balance billing inquiries
Analyze received correspondence; verify member eligibility, claim history and coordination of benefits
Review claims to determine if appropriate action was taken; follow up with Claims and Recovery Units to initiate adjustments and recover monies
Identify billing anomalies and alert the Fraud and Abuse Department to reduce fraudulent billing practices
Triage balance billing/fee negotiation inquiries and ensure all documents are processed in a timely and efficient manner
Research provider contracts and lease network reports to ensure providers are not breaching contracts by referring members out of network
Educate members and providers with out of network fees, out of pocket expenses and benefits of using the Funds network
Perform additional duties and projects as assigned by management
Qualifications
High School Diploma or GED required, some college or college degree preferred
Minimum two (2) years experience processing medical professional and facility hospital claims preferred
Experience negotiating bills and payments for managed care plans preferred
Knowledge of provider contracts and collections processes preferred
Excellent knowledge of health claims, eligibility rules, Coordination of Benefits (COB), 1199SEIU Benefit and Pension Fund and Retiree Benefits;
Knowledge of Current Procedural Terminology(CPT) codes, andInternational Classification of Diseases(ICD-10) codes preferred
Knowledge of health claims processing and benefit administration systems (QNXT and Vitech V3) preferred
Familiar with provider databases, web-based applications and call tracking systems (i.e. Cactus, IObserver, BeneFAQs, Member and Provider Portal)
Strong, analytical, and problem solving skills; able to work well independently and in a team oriented environment
Basic skill level in Word, Excel and Access required
Outstanding customer service skills; ability to maintain a pleasant attitude and provide excellent service to members and providers
Excellent oral and written communication skills; must be able to communicate clearly with members, staff and external partners
Must be able to work well under pressure, prioritize work with tight schedules and target dates in a high volume environment required
Detail oriented with demonstrated organizational skills; ability to multi-task and follow up
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