Other - CW Provider Disputes Support Specialist

Job Title

POSITION PURPOSE

Reviews processed claims to identify valid provider disputes. Creates and assigns dispute cases in EPIC to Provider Dispute Specialists for review and resolution. Coordinates intake, tracking, and distribution of provider disputes, appeals, and correspondence. Assists leadership with administrative support, case reporting, and file maintenance while ensuring compliance with privacy and regulatory requirements. Coordinates the review of all cases by recording and assigning all provider disputes. Prioritizes, organizes, distributes, and tracks incoming mail/case material. Records the flow of information and assigns it to the appropriate person/queues. Performs administrative and clerical support to PDRA.

NATURE AND SCOPE

This role does not manage people. This role reports to this job: SUPERVISOR, PROVIDER DISPUTES. Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with various internal and external entities including but not limited to, Member Services, Provider Services, Correspondence, Legal and Utilization Management, as well as members, hospitals and physician offices.

QUALIFICATIONS

Education: High School Diploma or equivalent is required.

Work Experience: 2 years of general medical/insurance office experience with either claims processing knowledge or provider/member servicing is required. Must have experience using Microsoft Office applications, including Word, Excel and PowerPoint. Facets experience is preferred.

Skills and Abilities Licenses and Certifications: None Required

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

Assist Manager and Supervisor with clerical/administrative tasks relating to the intake and reporting of all Department incoming cases. Assists with distribution of correspondence and internal referrals; and follow up with Department staff and internal departments as directed by management to ensure claims processing and benefit payments are completed consistent with information relayed to providers and within timeframes required by law, regulation, policy or other requirement. Forwards Medical Appeals, FEP appeals, and Correspondence to the appropriate departments in a timely manner. Assigns tasks to Provider Disputes Specialist based on review and research of the incoming provider disputes. Assists with preparing materials for appeal reviews (copying, creation of case binders, coordinate mailing or electronic communications, etc.) and distributing dispute cases and related information to reviewers. This includes ensuring all materials meet minimum necessary rule requirements consistent with internal policies and state/federal privacy laws. Assists with creating and maintaining electronic files and hard copy paper files; maintains and tracks department cases and files; assists with preparing and issuing reports required for various internal committee meetings and as needed on an ad hoc basis. Assists with updating database for all dispute cases. Assists with maintaining inventory of office supplies, maintain file of receipts and follows-up on outstanding orders. Navigates in Facets and Jiva systems to assess claims and authorizations for provider disputes, member appeals and medical appeals. Performs other duties as assigned.

Additional Accountabilities and Essential Functions The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions. Job duties are performed in a normal and clean office environment with normal noise levels. Work is predominately done while standing or sitting. The ability to comprehend, document, calculate, visualize, and analyze are required.

EEO: "Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans."