Medical Claim Relations Associate

EMC Insurance Companies

4d • Remote

About The Position

At EMC, we’re all about working together to make an impact. As part of our team, you’ll have the opportunity to grow, contribute, and gain experience that matters. We strive to be caring leaders, close partners, and responsive experts—always supporting each other to do our best work. Join us, and let’s improve lives together. This position is eligible to work from home anywhere in the United States Essential Functions: Operates as a main point of contact for the Medical Claims Review team for all inquiries, through both the customer service phone line, fax, and email Resolves escalated customer service calls from the bill review partner service center Resolves questions from medical providers and claims adjusters by researching claims and bills in both internal (File Handler, CLMS, Claims Center) and external (SmartAdvisor, Mitchell CEP) systems Provides information on payment status and explains bill review decisions by referencing explanation of review codes and other relevant data in the bill review system Assists customers in obtaining information regarding PPO networks and vendors used Communicates next steps for appeals to providers and claims adjusters, creates medical bill reconsideration in the appropriate system, and updates documentation in applicable bill review systems Guides customers to appropriate contact on escalated issues Follows up with customers as appropriate to resolve inquiries Searches policy system for active policies if a claim cannot be found and reaches out to the policyholder to check on claim status Provides data entry of medical bills as necessary, along with various bill auditing functions that cannot be completed by external resources Reviews and audits pended medical bills for accuracy of data entry Processes requests for refund in bill review system and composes letters to providers requesting the refund Reviews the business rules and assigned fee schedule of the bill review vendor to ensure compliance with EMC and the state business rules for all jurisdictions Contacts medical providers to request required billing forms and/or other information required to process billed charges Refers customers to vendor for electronic billing inquiries and informs medical providers of claim number concerns with electronic billing Contacts medical providers to obtain required tax forms and any other required documentation

Requirements

• High school diploma or equivalency
• Three years of medical office experience
• Good knowledge of medical terminology, including ICD-10 and CPT codes
• Ability to work in high volume, fast paced environment
• Strong attention to detail, multitasking, and organizational skills
• Ability to work effectively with others, as well as independently
• Excellent customer service skills, including verbal and written communication
• Working knowledge of state jurisdiction auditing rules and ability to research jurisdictions as needed
• Good knowledge of medical bill review procedures and state guidelines
• Strong computer skills, including knowledge of Microsoft Office Suite
• Accurate data entry skills

Nice To Haves

• Medical bill coding or auditing experience preferred
• Successful completion of medical terminology and medical coding courses
• Certified Professional Coder-Payer (CPC-P) designation preferred
• Prior customer service experience

Responsibilities

• Operates as a main point of contact for the Medical Claims Review team for all inquiries, through both the customer service phone line, fax, and email
• Resolves escalated customer service calls from the bill review partner service center
• Resolves questions from medical providers and claims adjusters by researching claims and bills in both internal (File Handler, CLMS, Claims Center) and external (SmartAdvisor, Mitchell CEP) systems
• Provides information on payment status and explains bill review decisions by referencing explanation of review codes and other relevant data in the bill review system
• Assists customers in obtaining information regarding PPO networks and vendors used
• Communicates next steps for appeals to providers and claims adjusters, creates medical bill reconsideration in the appropriate system, and updates documentation in applicable bill review systems
• Guides customers to appropriate contact on escalated issues
• Follows up with customers as appropriate to resolve inquiries
• Searches policy system for active policies if a claim cannot be found and reaches out to the policyholder to check on claim status
• Provides data entry of medical bills as necessary, along with various bill auditing functions that cannot be completed by external resources
• Reviews and audits pended medical bills for accuracy of data entry
• Processes requests for refund in bill review system and composes letters to providers requesting the refund
• Reviews the business rules and assigned fee schedule of the bill review vendor to ensure compliance with EMC and the state business rules for all jurisdictions
• Contacts medical providers to request required billing forms and/or other information required to process billed charges
• Refers customers to vendor for electronic billing inquiries and informs medical providers of claim number concerns with electronic billing
• Contacts medical providers to obtain required tax forms and any other required documentation

Benefits

• Outstanding benefits with life, medical, dental, vision and prescription drug coverage
• Competitive paid time off plan and a full day of volunteer time off annually
• Financial incentives, including a 401(k) plan match, pension plan, OneEMC bonus plan and recognition and anniversary awards
• Professional development and growth opportunities, including tuition reimbursement
• Wellness initiatives to improve team member well-being and reduce health insurance costs
• Flexibility to dress for your day and opportunities for alternative work arrangements

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED