Provider Relations Specialist

Blue Cross Blue Shield of Michigan•Lansing, MI

1d•Hybrid

About The Position

The Provider Relations Specialist serves internal and external customers contacting AF Group and provides accurate medical payment information. The position is hybrid, with one to four work-from-home days after training is completed. Provider Relations Specialist I handles incoming calls and provider inquiries, delivers customer service through phone, email, and fax, resolves or escalates issues, responds to questions about bill review analysis, and creates reconsiderations for processing. The role also requires careful handling of confidential information, accurate data entry, and dependable performance. Provider Relations Specialist II performs technical reviews of more complex medical bills, including outpatient hospital, multiple-surgery, modifier, anesthesia, and psychiatric bills. The specialist analyzes multi-state workers’ compensation medical claims, makes bill-review determinations under applicable state rules and regulations or third-party partner requirements, reviews bills and explanations of review for accuracy and compliance, and processes reconsiderations as needed.

Requirements

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

Nice To Haves

Background in Workers’ Compensation.
Degree or certification in Medical Coding.
Experience with an ACD telephone system.

Responsibilities

Use ACD phone lines to manage incoming calls and inquiries.
Provide customer service to internal and external customers by telephone, email, and fax.
Manage confidential client information with discretion and in accordance with department and company guidelines.
Identify problems, provide solutions, resolve issues promptly, and escalate complex problems appropriately.
Respond to written or verbal provider inquiries about bill-review analysis.
Analyze problems to determine root causes, then communicate and implement solutions.
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 billings to determine whether billed services are appropriate.
For Specialist II, make bill-review processing determinations according to applicable rules, regulations, and/or third-party partner requirements.
For Specialist II, evaluate medical bills and corresponding EORs for accuracy and compliance with state fee schedules, mandates, business rules, and guidelines.
For Specialist II, review inpatient hospital, outpatient hospital, and multiple-surgery billings.
For Specialist II, review, analyze, adjust, and release queued bills accurately and in a timely manner.
For Specialist II, consult fee schedules, CPT, ICD-CM, HCPCS, and other industry publications to support findings.
For Specialist II, process reconsiderations as needed.
Provide phone backup to the Provider Relations Team as needed.