Assist providers in response to telephonic and electronic inquiries and concerns on all products and paid/unpaid claims. Ensure that accurate information is being given to the provider in a timely manner and with the highest level of customer service. Handle Level One (1) provider inquiries this includes (but not limited to): general inquiries on claims processing, payment status and appeal and eligibility status verification. Document the interaction with the provider, including any resolution or escalation steps in the system of record for each call. Provide detailed information for each call including: Caller information; Information related to request/issue; Resolution information or escalation steps. Escalate Level Two (2) provider concerns to the Claims Department for resolution (e.g. Provider Disputes, incorrectly paid claims, payment check status, and Explanation of Benefits (EOB) requests. (50%)
Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.(20%)
Support the Call Center in meeting State regulatory requirements by handling member-related inbound calls. (10%)
Perform special projects and ad-hoc assignments when necessary. (10%)
Perform other duties as assigned. (10%)
