Summary/Objective:
The Workflow Coordinator works under general supervision to coordinate, monitor, and oversee workflow operations with the Claims Department. This role supports Claims Management and staff by tracking claims-related processes, facilitating workflow activities, monitoring operational timelines, and ensuring the efficient movement of medical claims and related information throughout the department.
Essential Functions:
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Coordinate subpoena requests by reviewing and compiling requested claims information, facilitating the collection of required documentation from other departments, and forwarding information to Fund counsel. Serve as a liaison with legal counsel to address questions and concerns regarding subpoena related matters.
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Facilitate the distribution of correspondence to members, authorized representatives, providers, etc. to support claims-related processes.
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Monitor and process Laserfiche requests in accordance with established procedures.
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Oversee the organization and maintenance of the training agenda library within OneNote to ensure information remains accessible, current and accurate.
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Monitor internal turnaround standards for claim processing and Salesforce cases, tracking workflow performance to support timely and accurate claim outcomes.
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Provide operational support for Salesforce and workflow related inquiries, facilitating issue resolution, escalating concerns when appropriate, and assisting staff with workflow processes and system navigation.
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Track Zelis stop-pay requests and coordination distribution to Claims Examiners for reissuance following confirmation.
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Review and triage Medicare and Medicaid paper claims, update Laserfiche records, and facilitate processing through the CMS electronic submission channel when appropriate.
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Monitor and track ICOB process notifications submitted to BCBS through the HUB, coordinating with Benefits & Eligibility to ensure ISSI records are updated and timely.
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Oversee and maintain tracking of QMSCO information received from Benefits & Eligibility to ensure timely follow-up and resolution.
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Monitor and route Salesforce cases, faxes, mail and ECMS items to the appropriate personnel to support efficient workflow management and timely resolution.
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Review incoming FSB claims to verify completeness and readability of documentation and coordinate responses when additional information is required.
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Track and report production metrics and downtime activity through departmental dashboards to support operational performance monitoring.
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Monitor and update provider profile information, payer contacts, W-9 documentation, and TIN records to maintain data integrity.
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Monitor and update departmental records, including examiner credentials, contact information and other operational tracking resources.
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Coordinate approval workflows and secure required authorizations for member and legal correspondence.
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Maintain provider information within various workflow applications.
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Provide backup support for priority claim assignment processes, including out-of-network returned claims with pricing and claims requiring negotiation approval.
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Coordinate fulfillment of large-volume Explanation of Benefits (EOB) copy requests.
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Complete CMS-related claim inquiries and facilitate timely resolution and submissions to
CMS and Medicaid agencies. -
Provide backup operational support for the bi-weekly check run process to ensure continuity of workflow.
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Support monitoring and reporting activities associated with daily aging queues.
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Montior office supply inventory levels and place orders, when necessary.
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Audit bad-address claims, coordinate research efforts with Records and Information Management, and facilitate claim reissuance once updated information is obtained.
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Provide back-up support for distribution and tracking of straggler claims assigned for clean-up and resolution.
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Other duties as assigned.
Education and Experience:
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High School diploma or equivalent
Specialized Skills/Technical Knowledge:
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Knowledge of medical terminology and medical claims preferred.
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Ability to perform effectively in a high-volume, quality-focused work environment.
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Professional communication skills, both verbally and in writing.
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Knowledge of healthcare coding systems and methodologies, including CPT, ICD-10, and DRG preferred.
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Strong organizational, analytical and problem-solving, and follow-up skills.
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Proficiency in Microsoft Office applications, including Word and Excel.
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Ability to learn and effectively utilize workflow management systems, document management platforms, and claim processing applications.
