Claims Workflow Coordinator

Job Description

Job Description

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:

• 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. 
• Facilitate the distribution of correspondence to members, authorized representatives, providers, etc. to support claims-related processes. 
• Monitor and process Laserfiche requests in accordance with established procedures. 
• Oversee the organization and maintenance of the training agenda library within OneNote to ensure information remains accessible, current and accurate. 
• Monitor internal turnaround standards for claim processing and Salesforce cases, tracking workflow performance to support timely and accurate claim outcomes. 
• 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. 
• Track Zelis stop-pay requests and coordination distribution to Claims Examiners for reissuance following confirmation. 
• Review and triage Medicare and Medicaid paper claims, update Laserfiche records, and facilitate processing through the CMS electronic submission channel when appropriate. 
• Monitor and track ICOB process notifications submitted to BCBS through the HUB, coordinating with Benefits & Eligibility to ensure ISSI records are updated and timely. 
• Oversee and maintain tracking of QMSCO information received from Benefits & Eligibility to ensure timely follow-up and resolution. 
• Monitor and route Salesforce cases, faxes, mail and ECMS items to the appropriate personnel to support efficient workflow management and timely resolution.
• Review incoming FSB claims to verify completeness and readability of documentation and coordinate responses when additional information is required.
• Track and report production metrics and downtime activity through departmental dashboards to support operational performance monitoring. 
• Monitor and update provider profile information, payer contacts, W-9 documentation, and TIN records to maintain data integrity. 
• Monitor and update departmental records, including examiner credentials, contact information and other operational tracking resources. 
• Coordinate approval workflows and secure required authorizations for member and legal correspondence. 
• Maintain provider information within various workflow applications. 
• Provide backup support for priority claim assignment processes, including out-of-network returned claims with pricing and claims requiring negotiation approval. 
• Coordinate fulfillment of large-volume Explanation of Benefits (EOB) copy requests. 
• 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. 
• Support monitoring and reporting activities associated with daily aging queues. 
• Montior office supply inventory levels and place orders, when necessary.
• Audit bad-address claims, coordinate research efforts with Records and Information Management, and facilitate claim reissuance once updated information is obtained. 
• Provide back-up support for distribution and tracking of straggler claims assigned for clean-up and resolution.
• Other duties as assigned.

Education and Experience:

• High School diploma or equivalent

Specialized Skills/Technical Knowledge:

• Knowledge of medical terminology and medical claims preferred.
• Ability to perform effectively in a high-volume, quality-focused work environment.
• Professional communication skills, both verbally and in writing.
• Knowledge of healthcare coding systems and methodologies, including CPT, ICD-10, and DRG preferred.
• Strong organizational, analytical and problem-solving, and follow-up skills. 
• Proficiency in Microsoft Office applications, including Word and Excel.
• Ability to learn and effectively utilize workflow management systems, document management platforms, and claim processing applications.