Provider Relations Specialist

Job Description

Provider Relations Specialist I: Responsible for servicing internal and external customers who contact AF Group via the ACD phone line. Responsible for providing quality, consistent and accurate medical payment information to internal and external customers. Provider Relations Specialist II: Responsible for analyzing billings including outpatient hospital and multiple surgeries by utilizing our Medical Bill Review (MBR) software and reference library to determine appropriateness of codes and excessive charges. Responsible for making coding determinations according to state rules and regulations.

PRIMARY RESPONSIBILITIES:

• Provider Relations Specialist I:
• Utilizes ACD phone lines to manage incoming calls and inquiries.
• Provides high level of customer service for all internal or external customers thru telephonic, email and fax.
• Demonstrates dependable work ethic.
• Manages confidential client information with discretion and good judgement in accordance with department and company guidelines.
• Identifies problems, provides solutions and resolves promptly, escalating more complex problems appropriately.
• Responds to written or verbal provider inquiries relating to our bill review analysis.
• Analyzes problems using problem solving methodology skills to determine root cause; communicates and implements solutions.
• Types, photocopies, faxes as necessary.
• Create reconsiderations for processing.
• Additional responsibilities of Provider Relations Specialist II:
• Responsible for performing technical review of more complex medical bills, including but not limited to modifiers, anesthesia, & psychiatric.
• Responsible for analyzing complex billings for multi-state Workers Compensation medical claims to determine appropriateness of services billed.
• Responsible for making bill review processing determination according to rules and regulations and/or third-party partner.
• Evaluates medical bills and corresponding EOR's for accuracy and compliance with state mandate fee schedule(s) and our business rules and guidelines.
• Reviews inpatient hospital, outpatient hospital, and multiple surgery billings.
• Reviews, analyzes, adjusts and releases queued bills in an accurate and timely manner.
• Refers to reference library of fee schedules, CPT, ICD-CM, HCPCS, and other industry publication to support findings.
• Processes reconsiderations, as needed.
• Phone backup to Provider Relations Team as may be needed.

EMPLOYMENT QUALIFICATIONS:

A. EDUCATION REQUIRED:

• Provider Relations Specialists I: High School Diploma or G.E.D. required. Completed coursework or enrolled in Medical Insurance Billing and Coding Certificate, required.
• Provider Relations Specialists II: Certificate in Medical Billing, required.

B. EXPERIENCE REQUIRED:

• Provider Relations Specialists I: Minimum of three-year general office experience including answering inquiries over the phone or equivalent relevant experience that would provide the required skills, knowledge, and abilities.
• Provider Relations Specialists II: Two years as a Provider Relations Specialist I. OR Three years' experience in an insurance organization with two years demonstrated technical knowledge in workers' compensation medical bill review or other relevant experience, which provides necessary skills, knowledge, and abilities.

C. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Provider Relations Specialists I:
• Excellent customer service skills.
• Excellent telephone etiquette.
• Knowledge of multi-functional phone system.
• Ability to obtain pertinent and thorough information from customers.
• Knowledge of computers and spreadsheet software.
• Ability to type 40 wpm accurately.
• Ability to proofread documents for accuracy of spelling, grammar, punctuation, and format.
• Ability to perform mathematical calculations with the ability to use a ten-key pad with accuracy.
• Ability to multi-task, i.e., interact on telephone while entering data.
• Ability to manage work with minimal direction.
• Excellent oral and written communication.
• Demonstrate attention to detail.
• Ability to consistently meet or exceed daily production and quality standard for this position.
• Additional Skills Required for Provider Relations Specialist II:
• Working knowledge, experience, and ability to process bills using state medical payment methodologies.
• Ability to use independent discretion to make choices on proper reimbursement.
• Thorough knowledge of Worker's Compensation multi state medical fee schedules, Medical guidelines, medical terminology and CPT/ICD-CM.
• Basic knowledge of Workers Compensation Act.

D. ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED:

• Background in Workers Compensation preferred.
• Degree or Certification in Medical Coding.
• Experience on an ACD telephone system.

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards.