Provider Relations Specialist

Blue Cross Blue Shield of Michigan•Lansing, MI

1d•Onsite

About The Position

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

Requirements

Provider Relations Specialists I: High School Diploma or G.E.D. required.
Provider Relations Specialists II: Certificate in Medical Billing, 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.
Provider Relations Specialists I: Excellent customer service skills.
Provider Relations Specialists I: Excellent telephone etiquette.
Provider Relations Specialists I: Knowledge of multi-functional phone system.
Provider Relations Specialists I: Ability to obtain pertinent and thorough information from customers.
Provider Relations Specialists I: Knowledge of computers and spreadsheet software.
Provider Relations Specialists I: Ability to type 40 wpm accurately.
Provider Relations Specialists I: Ability to proofread documents for accuracy of spelling, grammar, punctuation, and format.
Provider Relations Specialists I: Ability to perform mathematical calculations with the ability to use a ten-key pad with accuracy.
Provider Relations Specialists I: Ability to multi-task, i.e., interact on telephone while entering data.
Provider Relations Specialists I: Ability to manage work with minimal direction.
Provider Relations Specialists I: Excellent oral and written communication.
Provider Relations Specialists I: Demonstrate attention to detail.
Provider Relations Specialists I: 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.
Additional Skills Required for Provider Relations Specialist II: Ability to use independent discretion to make choices on proper reimbursement.
Additional Skills Required for Provider Relations Specialist II: Thorough knowledge of Worker’s Compensation multi state medical fee schedules, Medical guidelines, medical terminology and CPT/ICD-CM.
Additional Skills Required for Provider Relations Specialist II: Basic knowledge of Workers Compensation Act.

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.
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.