Position is located in Pittsburgh, PA.
GENERAL SUMMARY
Provides coordination and support to assist with the research, compilation, accuracy, and approval of required government filings. Responsible for Health Plan compliance with all filings and documentation for the assigned Medicare plan. 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 member complaints, 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. Supports, and assists in training of new staff members. NOTE: This is not a secretarial position.
ESSENTIAL RESPONSIBILITIES
Monitors and evaluates efforts during the group/provider set-up, enrollment process and/or claims payment and benefit interpretation according to contractual agreements, and industry standards.
May resolve any inaccuracies or deviations identified during the monitoring process and champions process improvement initiatives.
Coordinates a variety of administrative assignments by outlining data requirements, working with various departments to obtain necessary data, providing analysis, and preparing documentation and files for required government filings.
Designs and implements procedures, at the direction of management, to identify and analyze trends in member complaints, group/provider set-up, enrollment, and deviations in policy applications.
Responsible for accurate, timely documentation and quality checking of information necessary for government filings.
Responsible for obtaining approval from Centers for Medicare and Medicaid Services on required documents and processes.
In conjunction with various internal and external parties, participates in workgroups that guide process related to the Medicare plans.
Participates in meetings; presentation summaries; plans agendas; manages logistics; researches and analyzes data to prepare reports; provides general support and follow-up as needed.
May attend sales or benefits meetings to ensure understanding of plan functions and the effectiveness of our sales items. .
May provide oversight for plan budget usage.
May serve as subject matter expert for the department policies and procedures.
Performs other duties as required.
Ideal candidates will posses the following:
- High school degree or equivalent. Bachelor’s degree preferred.
- Previous experience in group set up, enrollment, and direct customer service.
- Previous auditing or quality assurance experience preferred.
- Previous experience with Centers for Medicare and Medicaid Services filing requirements.
- Superior attention to detail and accuracy, proofreading skills are essential
- Strong written and verbal communication skills.
- Ability to meet deadlines and work under pressure.
- Demonstrated analytical, problem solving, and documentation skills.
- Ability to use standard computer software packages and applications.
- Familiarity with health plan benefit structure is 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: Pittsburgh, PA, US
Organization: 23000 - HealthAmerica Pennsylvania Inc
Schedule: Full-time
Job Posting: 2013-01-02 00:00:00.0
Job ID: 1212788