Provider Relations Specialist

Emergent Holdings•Lansing, MI

3h•Onsite

About The Position

This role is for a Provider Relations Specialist, with two levels: Provider Relations Specialist I and Provider Relations Specialist II. The Specialist I is responsible for servicing internal and external customers via phone, providing accurate medical payment information. The Specialist II analyzes billings using Medical Bill Review (MBR) software and reference materials to determine the appropriateness of codes and charges, making coding determinations according to state rules and regulations.

Requirements

High School Diploma or G.E.D. required for Specialist I.
Completed coursework or enrolled in Medical Insurance Billing and Coding for Specialist I.
Certificate in Medical Billing, required for Specialist II.
Minimum of three-year general office experience including answering inquiries over the phone or equivalent relevant experience for Specialist I.
Two years as a Provider Relations Specialist I for Specialist II.
OR Three years’ experience in an insurance organization with two years demonstrated technical knowledge in workers’ compensation medical bill review or other relevant experience for Specialist II.
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.
Working knowledge, experience, and ability to process bills using state medical payment methodologies for Specialist II.
Ability to use independent discretion to make choices on proper reimbursement for Specialist II.
Thorough knowledge of Worker’s Compensation multi state medical fee schedules, Medical guidelines, medical terminology and CPT/ICD-CM for Specialist II.
Basic knowledge of Workers Compensation Act for Specialist II.

Nice To Haves

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

Responsibilities

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.
Performs technical review of more complex medical bills, including but not limited to modifiers, anesthesia, & psychiatric.
Analyzes complex billings for multi-state Workers Compensation medical claims to determine appropriateness of services billed.
Makes 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.