Responsible for supervising workflow of all incoming calls and cases for area of responsibility (e.g., triage, benefits, claims, appeals, etc.) which includes developing and implementing policies and procedures, training staff to perform specific functions and managing employee performance.
Monitor calls and audit case files daily to ensure the proper target resolution is identified and that, if possible, the case is closed at or near the target resolution and implement actions to resolve any case deficiencies which includes reviewing results with employees.
Review operational reports and analyze staffs needed and make the necessary adjustments and or plans to improve results, which includes, adherence to hours worked, time spent resolving cases, and case documentation.
Analyze data reports to make timely decisions and effectively implement plans
Associate's degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field required
Minimum of 3 years of healthcare, health plan or benefits experience required preferably in a call center environment
Minimum one year lead or supervisor experience preferred
Based on department or area of assignment the following may be required: Minimum 2 years of health benefits or health insurance appeals experience Minimum 1 years of claims or claims processing experience
*Intermediate knowledge of Word and Excel is required
*Ability to search and identify resources through company Intranet and Internet *Based on assignment may need to be bilingual in English, Spanish, etc. Based on department or assignment knowledge of the following is preferred: *Group Health Plans (fully insured and self-insured)
*Summary Plan Documents (SPDs) and Certificates of Coverage (COCs) *Government programs, resources and legislation and mandates including but not limited to Affordable Care Act, FMLA, Medicaid, CHIP
*Medicare A, B, MediGap, Supplement plans, Medicare Advantage, Medicare Part D plans
*High deductible health plans including Health Reimbursement Accounts (HRAs) and Health Saving Accounts (HSAs)
*Flex Spending Accounts (FSA) , including limited FSAs
*Coordination of benefits and which plan is primary - simple and complex cases (commercial plans, Medicare plans)
*Pharmacy benefits including injectable medications
*Individual Health Plans and Exchanges plans
*Reviewing, interpreting, and researching Explanation of Benefits (EOB's) and denial letters
*Understanding of health plan authorizations, including medical policy and claims payment guidelines to evaluate if appeals require clinical or administrative review
*Knowledge of applicable law and resources regarding confidentiality of privileged patient information and appeals administration
*Understanding of insurance carrier claims processing
*Knowledge of procedure and diagnosis coding (ICD-9, HCPCS, and CPT-4)