The Insurance/Healthcare job family contains positions associated with providing consultancy utilizing knowledge and expertise on insurance and healthcare. Develops and implements general insurance and health policies in accordance with state and federal laws. Provides expertise to investigate and adjudicate claim characteristics that do not match policy provisions. Responds to provider appeals and meets with providers to resolve problems/issues. Provides directions for utilization review. Approves any remedial or recoupment actions associated with escalated claims. Advises provider review councils, state officials and works with organized healthcare groups and associations on various medical issues related to insurance and healthcare programs
Participates productively as member of team.
Completes general tasks.
Accepts instruction and direction to complete basic assignments from leadership and peers.
Identifies and escalates questions or issues.
Complies with contractrequirements, business unit rules and related industry and legal regulations.
Education and Experience Required:
High School Diploma or equivalent; may hold 2 year post-high school Degree.
Typically, 0-1 year of working experience.
Knowledge and Skills:
Some prior office or clerical experience.
Ability to receive and act on clear concise instructions from leadership.
Basic PC (personal computer) skills as required by the work unit.
Ability to use the telephone for business purposes.
Ability to follow procedural guidelines.
Good written and verbal communication.