Provider Relations Specialist

Emergent Holdings•Lansing, MI

1d•Hybrid

About The Position

The Provider Relations Specialist serves internal and external customers contacting AF Group, providing customer service and accurate medical payment information. Specialist I manages inquiries through phone, email, and fax, responds to provider questions about bill review analysis, identifies and resolves issues, and creates reconsiderations for processing. After training, the position is hybrid, with 1–4 work-from-home days. Specialist II also performs technical reviews of complex medical bills and analyzes multi-state workers’ compensation claims. This includes checking bills and explanations of review for accuracy and compliance with state fee schedules, mandates, business rules, and partner requirements; reviewing hospital and multiple-surgery bills; adjusting and releasing queued bills; and using industry references to support findings. Specialist II processes reconsiderations and may provide phone backup to the Provider Relations Team. Work is performed in an office setting with no unusual hazards.

Requirements

Specialist I: High school diploma or GED.
Specialist I: Completed coursework in, or enrollment in, Medical Insurance Billing and Coding.
Specialist I: At least three years of general office experience, including answering telephone inquiries, or equivalent relevant experience.
Specialist II: Certificate in Medical Billing.
Specialist II: Either two years as a Provider Relations Specialist I, or three years’ experience in an insurance organization with two years of demonstrated technical knowledge in workers’ compensation medical bill review, or other relevant experience providing the required skills, knowledge, and abilities.
Excellent customer service skills and telephone etiquette.
Knowledge of a multifunction phone system.
Ability to obtain pertinent and thorough information from customers.
Knowledge of computers and spreadsheet software.
Ability to type 40 words per minute accurately.
Ability to proofread documents for spelling, grammar, punctuation, and formatting accuracy.
Ability to perform mathematical calculations and use a ten-key pad accurately.
Ability to multitask, including entering data while interacting on the telephone.
Ability to manage work with minimal direction.
Excellent oral and written communication skills and attention to detail.
Ability to consistently meet or exceed daily production and quality standards.
Specialist II: Working knowledge and experience processing bills using state medical payment methodologies.
Specialist II: Ability to use independent discretion to make reimbursement decisions.
Specialist II: Thorough knowledge of multi-state workers’ compensation medical fee schedules, medical guidelines, medical terminology, and CPT/ICD-CM.
Specialist II: Basic knowledge of the Workers’ Compensation Act.

Nice To Haves

Background in workers’ compensation.
Degree or certification in medical coding.
Experience using an ACD telephone system.

Responsibilities

Manage incoming calls and inquiries using ACD phone lines.
Provide customer service to internal and external customers by phone, email, and fax.
Handle confidential client information discreetly and in accordance with department and company guidelines.
Identify problems, determine root causes, implement solutions, and escalate complex issues when appropriate.
Respond to written and verbal provider inquiries about bill review analysis.
Type, photocopy, and fax documents as needed.
Create reconsiderations for processing.
For Specialist II, technically review complex medical bills, including bills involving modifiers, anesthesia, and psychiatric services.
For Specialist II, analyze complex multi-state workers’ compensation medical bills to determine whether billed services are appropriate.
For Specialist II, make bill review processing determinations according to applicable rules, regulations, and third-party partner requirements.
For Specialist II, evaluate medical bills and related EORs for accuracy and compliance with state fee schedules, mandates, business rules, and guidelines.
For Specialist II, review inpatient and outpatient hospital bills and multiple-surgery bills.
For Specialist II, review, analyze, adjust, and release queued bills accurately and promptly.
For Specialist II, consult fee schedules, CPT, ICD-CM, HCPCS, and other industry publications to support review findings.
For Specialist II, process reconsiderations as needed and provide phone backup to the Provider Relations Team when needed.