Provider Relations Specialist

Blue Cross Blue Shield of Michigan•Lansing, MI

15h

About The Position

Provider Relations Specialists service internal and external customers contacting AF Group through its ACD phone line and provide accurate medical payment information. Specialist I handles customer inquiries and provider questions about bill review analysis, resolves problems, creates reconsiderations, and provides support through telephone, email, and fax. Specialist II also conducts technical reviews of complex medical bills and multi-state workers’ compensation claims, determines whether billing and services comply with applicable rules and fee schedules, and processes bill adjustments and reconsiderations.

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 phone 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 of experience in an insurance organization, including two years of demonstrated technical knowledge in workers’ compensation medical bill review, or equivalent relevant experience.
Excellent customer service skills and telephone etiquette.
Knowledge of a multifunction phone system, computers, and spreadsheet software.
Ability to obtain thorough and relevant information from customers.
Ability to type accurately at 40 words per minute and proofread documents for spelling, grammar, punctuation, and format.
Ability to perform mathematical calculations and accurately use a ten-key pad.
Ability to multitask, including entering data while speaking on the telephone.
Ability to manage work with minimal direction.
Excellent oral and written communication skills and attention to detail.
Specialist II: Working knowledge and experience processing bills using state medical payment methodologies.
Specialist II: Ability to exercise independent discretion in determining proper reimbursement.
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 with an ACD telephone system.

Responsibilities

Manage incoming calls and inquiries through ACD phone lines.
Provide customer service to internal and external customers by telephone, email, and fax.
Handle confidential client information according to department and company guidelines.
Identify, analyze, and resolve problems, escalating complex issues as appropriate.
Respond to written and verbal provider inquiries about bill review analysis.
Create reconsiderations for processing; Specialist II processes reconsiderations as needed.
Perform technical reviews of complex medical bills, including bills involving modifiers, anesthesia, and psychiatric services.
Analyze complex billings for multi-state workers’ compensation medical claims to determine whether services billed are appropriate.
Make bill-review processing determinations according to applicable rules, regulations, and third-party partner requirements.
Evaluate medical bills and corresponding EORs for accuracy and compliance with state fee schedules, mandates, business rules, and guidelines.
Review inpatient hospital, outpatient hospital, and multiple-surgery billings.
Review, analyze, adjust, and release queued bills accurately and promptly.
Use fee schedules, CPT, ICD-CM, HCPCS, and other industry publications to support findings.
Provide phone backup to the Provider Relations Team as needed.
Type, photocopy, and fax documents as necessary.
Meet daily production and quality standards.