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TITLE
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DEPARTMENT
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DESCRIPTION
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Claims Analyst
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Claims
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Reviews and adjudicates provider claims up to a certain complexity level. To maintain in strict confidence, all HCP, member, provider and Healthplan information to which the Professional Claims Adjudication Analyst has access. Determine eligibility of members, acceptability of evidence submitted, and necessity for additional information or review, resolve issues before claims payment to avoid re-adjudication. Ability to work with speed and accuracy in a busy environment is essential. 2+ years exp. HMO/MSO or IPA claims examining/adjudication experience, along with a thorough knowledge of CPT and ICD 9 codes.
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Facility/Hospital Claims Analyst
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Claims
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Reviews and adjudicates provider claims up to a certain complexity level. To maintain in strict confidence, member, provider and Health plan information to which the Hospital Claims Adjudication Analyst has access. Must have a working knowledge of hospital Revenue, CPT-4, HCPCS and ICD-9 coding. Ability to review, interprets, and applies facility contract rates as applicable. Knowledge of CMS claims processing guidelines. Strong knowledge of Microsoft Windows environment. Self-starter, willing to take on multiple tasks. Strong knowledge of Coordination of Benefits (COB) applications. Must be able to interpret health plan benefits.
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Auditor
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Claims
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Conduct internal audits on professional and hospital claims. Identify, proactively through auditing and internal reporting, negative and positive trends and initiate recommendations for change. Must have a working knowledge of CPT-4, HCPCS, Revenue and ICD-9 coding. Experienced with professional and hospital claims adjudication. Knowledge of HCFA claims processing guidelines. Knowledge of correct coding guidelines. Must meet minimal corrected keystroke requirements of 10,000 keystrokes/5 minutes. Minimum 3 years healthcare claims processing experience preferably in a managed care setting.
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Contracting Representative
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Contracting
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Responsible for recruitment of primary care physicians. Must have 2+ years proven successful sales experience and excellent negotiating skills. Must have a car. Local travel required.
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Customer Service Representative
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Customer Service
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Ensure all callers receive exceptional service through dedication and professionalism. Answer incoming calls in a fast paced, high volume environment with accuracy and efficiency. Accountable for resolving claims, eligibility, authorization and other related inquires from providers, members and health plan representatives with follow-up. Access on-line member and provider information through EZ CAP. Exceptional organizational, time management and follow-up skills. Must be motivated to work independently and have the ability to multi-task. Knowledge of medical terminology and/or medical billing preferred.
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Decision Support Analyst
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Database Management
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Load providers into the EZ-CAP system in order for Utilization Management and Claims Department to authorize & pay claims for eligible members to contracted providers. Knowledge of Microsoft Word and Excel. Must be self starter and work well with internal departments.
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Director of IT
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Information Technology
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Under limited supervision, coordinates distribution of data analysis tools, reports, and operational products to the end-users, ensures the availability of up to date data in standard formats for analysis, coordinates the installation, maintenance, and trouble-shooting of data-entry and data analysis software. Bachelor’s Degree required. Training in Microsoft Access 97. Advanced knowledge of EZCap 5.3 for Windows a plus. Data Analysis skills using MS Access, and Crystal reports required. Intermediate knowledge of Structured Query Language a must.
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Ancillary Provider Liaisons
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Provider Services
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Primary resource for identifying, evaluating and negotiating contracts with prospective ancillary providers. Front-line support and data maintenance for ancillary/facility providers. Requires knowledge of managed care contracting concepts. Strong written and verbal communication skills. Proficient with Microsoft Word, Access and Excel. Can work effectively in cross-departmental assignments.
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Provider Services Representatives
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Provider Services
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Initiate and maintain strong, positive working relationship with physicians and office staff, solving problems in an effective, expedient manner and meet their needs to increase satisfaction. Knowledge of capitation, physician office operations and the effect of managed care on a physician’s practice. Demonstrated marketing and customer relations’ skills to interact with physicians, and their office staffs to maintain high satisfaction. Ability to interact effectively with unhappy or dissatisfied customers/constituents.
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Patient Care Coordinator
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Utilization Management
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Receive daily notification calls/faxes regarding members admitted to acute hospitals. Initiate authorization, case, and inpatient intake form on member for elective/emergency admissions. Documentation of readmission/past medical history on intake form. Investigation of financial status of the acute facility. Identification of COB issues that should be investigated by the UM benefit/eligibility specialist. (I.e. Medicare prime/no-fault). Daily discharge calls on all acute facility inpatient members. Daily faxing out to the UM departments on all acute facility inpatient members. Outbound calls as needed for the inpatient case managers. Requirements: Strong medical terminology and ICD-9 CPT coding background. 3-5 years managed care experience.
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Credentialing Lead
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Utilization Management
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To ensure that all practitioners demonstrate the ability to reliably and predictably meet company standards of care and service. The requirements of the credentialing process are designed to meet the standards of the National Committee for Quality Assurance (NCQA). Experience in processing initial/reappointment applications and conducting credentials verification and follow-up. Knowledge of accreditation standards, excellent communication skills, both oral and written. Must demonstrate initiative, resourcefulness and problem solving skills. Proficiency in organization and prioritization of work, establishing procedures and systems and ensuring orderly and timely flow of business through the credentialing department. 2+ years credentialing experience required.
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Certified Medical Assistant
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Utilization Management
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The Certified Medical Assistant will work interdependently with other health care professionals to assist with providing quality care to a select group of patients. Must be a certified registered medical assistant with a current registration or certification. Must have 3 years minimum in a clinical/medical setting. Familiarity with managed care concepts.
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Referral Coordinator
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Utilization Management
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The Referral Coordinator sorts and separates referral requests to be reviewed by nurses and medical directors based upon specialty and service codes. To be responsible for assuring that referral requests are complete, members are being referred to par providers, benefit limitations are adhered to, and benefit coverage is interpreted correctly. To be responsible, as the designated clinical representative, for notifying providers and members of the final determination for reviewed referral requests. Requires a strong knowledge of medical terminology. ICD-9 and CPT-4 coding background. Proven ability to manage multiple assignments simultaneously.
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Priority Care RN Case Manager
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Utilization Management
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To facilitate the coordination of quality patient focused care for a select group of high-risk patients. To monitor care, identify variances, and facilitate progress towards expected outcomes across the continuum of patient care. NYS RN license required. Minimum of five years med/surg experience. Minimum of five years UM/Case Management experience in managed care environment. Experience with UM and QI process. Experience with patient/staff education.
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Sales and Enrollment Assistant
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Marketing
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Responsible for data entry and production of reports pertaining to enrollment and dis-enrollment of senior health plan members. Data entry and production of weekly/monthly reports of all information generated from: leads received during sales events, outbound telephone calls to members that have terminated their membership, outbound telephone calls to new members. Track results & generate reports of sales activity from sales representatives and brokers, calls, appointments, denials, and application submissions. Requires At least 3 years working extensively with Microsoft, Excel and Access, in particular, Including generation of reports and graphs.
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