GENERAL SUMMARY
Leads the monitoring and evaluation efforts of claims payment according to provider contracts and/or group/provider set-up, eligibility according to contractual agreement, evidence of coverage, and industry standards. Identifies and analyzes trends in group/provider set-up, claims and/or enrollment inaccuracies, and deviations in policy applications including problem resolution. Develops and implements procedures to address and correct any resulting issues.
ESSENTIAL RESPONSIBILITIES
- Leads the monitoring and evaluation efforts during the group/provider set-up, enrollment process and/or claims payment and benefit interpretation according to contractual agreements, and industry standards.
- Monitors tracking of claims payment errors, group/provider set up, enrollment, vendor interface and data transmission processes. Reports and communicates findings to management.
- Responsible for resolving any inaccuracies or deviations identified during the review process. Reviews and resolves group, provider, interdepartmental, vendor and health plan, and/or claims issues or inquiries related to processes according to review guidelines.
- May resolve any inaccuracies or deviations identified during the claims review process and champions process improvement initiatives. Approves and denies reimbursement based upon established review criteria.
- Reviews and resolves provider and member inquiries related to claims processed according to review guidelines of benefit interpretation.
- Designs and implements procedures, at the direction of management, to identify and analyze trends in member complaints, claims, group/provider set-up, enrollment, and claims payment inaccuracies and deviations in policy applications.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Bachelor’s degree or equivalent experience.
- Significant experience (usually 5+ years) in claims payment.
- Previous auditing or quality assurance experience preferred.
- Three years of experience with electronic data transmission.
- Strong communication and interpersonal skills.
- Strong analytic and problem solving abilities.
- Knowledge of IDX, Excel and Access preferred.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Austin, TX, US
Other Locations: St. Louis-Missouri-United States,
Organization: 51000 - MHNet Specialty Services, LLC
Schedule: Full-time
Job Posting: 2012-10-23 00:00:00.0
Job ID: 1211311