GENERAL SUMMARY
Provides support to CoventryCares of Virginia (Medicaid). Evaluates and monitors group/provider set-up, eligibility according to contractual agreement, evidence of coverage, industry standards, and claims payment process. Responsible for identifying and verifying trends in member complaints, group/provider set-up, claims and enrollment inaccuracies, and deviations in policy application. Determines appropriate corrective action and/or resolution to improve customer service.
ESSENTIAL RESPONSIBILITIES
- Reviews, investigates, and applies guidelines to identify inaccuracies during the group/provider set-up, enrollment process, or claims review process.
- Provides ongoing analysis of the group/provider set-up and the enrollment or claims processes. Analyzes reports to validate accuracy of system. Identifies trends and recommends improvements to internal processes to improve customer service.
- Assists with the review and resolution of vendor, group, broker, provider, interdepartmental and health plan provider inquiries related to the group/provider set-up, and enrollment or claims processes.
- Monitors, analyzes, and reports claim payment administration, benefit administration, and enrollment processing errors.
- Monitors the application of policies and procedures during the review process to identify deviations from industry standards.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- High school degree or equivalent. Bachelor’s degree preferred.
- Significant experience (usually 4-5 years) in group set-up, enrollment and direct customer service.
- Previous auditing or quality assurance experience preferred.
- Knowledge of group set-up, eligibility requirements, ICD-9 and CPT codes.
- Strong communication and interpersonal skills.
- Strong analytic and problem solving abilities.
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: Richmond, VA, US
Organization: 25400 - Coventry Health Care of Virginia, Inc.
Schedule: Full-time
Job Posting: 2013-01-23 00:00:00.0
Job ID: 1310268