Operations Resolution Specialist MCHP – Provider Data Management

Trinity Health • Columbus, OH

20h

About The Position

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. They are dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. They rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more. MediGold invests in great people and asks that colleagues come to work ready to make a difference and do the right thing. The Operations Resolution Specialist researches, analyzes, documents, and coordinates the resolution of escalated and/or complex issues pertaining to claims, member services, network operations and RAPS and EDPS submissions. This role serves as a department subject matter expert and requires knowledge of all Plan systems, tools, policies and procedures.

Requirements

• Associate or Bachelor's degree preferred
• Claims department: CPC, CPC-P or equivalent required
• Member Services department: Active State of Ohio Insurance License (Life and Health) or obtained within 90 days of hire
• One to three years experience preferred in either managed care health insurance, or customer service disciplines
• Knowledgeable in provider coding and billing requirements
• Knowledgeable with provider credentialing and contracting terminology
• Basic knowledge of the healthcare claims process
• General knowledge of current medical terminology, anatomy and physiology

Responsibilities

• Responds to sensitive, escalated and difficult inquiries.
• Researches, resolves and responds to such inquiries in a timely, compliant and courteous manner.
• Determines trends and provides education and feedback related to escalated questions and issues.
• Coordinates the identification of root causes for errors and works with multiple operational areas across the Plan to fully resolve identified errors.
• Generates reports as necessary to monitor processes.
• Assists in the development and maintenance of department policies and procedures.
• Functions as a team member by serving as a department resource and subject matter expert
• Assists in the development of tools and presentations on documentation, coding, billing, and other requirements necessary for complete encounter data submissions
• Works proactively with external vendors to troubleshoot encounter errors and correction of necessary inbound data

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Number of Employees: 251-500 employees