Avp, Provider Claim Resolution - New York, United States - ConnectiCare
Description
Summary of Position
Serve as the key operational liaison with Provider Network Management and Finance: responsible for the reconciliation, reprocessing/recoupment and provider communication for claim payment integrity challenges.
Drive discussions directly with all Provider back office operations to resolve claim processing disputes, including over and under payments, in a timely manner with engagement from the Provider Network Management Relationship Managers to ensure the discussions follow the contractual agreement.
Responsibilities:
- Direct team to review claim A/R files, determine root causes and trends, build and implement corrective action plans, and drive reprocessing of claims where applicable.
- Ensure alignment between stakeholders of all processes related to overpayments/pay cycles: collaborate with Finance and other departments as needed to build, implement, maintain, and enhance a process to maximize efficiency and effectiveness of overpayment offset reconciliations.
- Drive discussions directly with Provider back office operations to explain findings and to obtain agreement from Provider back office operations on financial determinations from over/under payments. Take steps to ensure that the work is fully integrated into a cohesive review of under and overpayments with the providers.
- Prioritize and schedule claim reprocessing through manual adjustments and recycle programs in alignment with Finance to ensure appropriate and timely cash flow release.
- Collaborate with Contract Configuration Team, Grievance & Appeals, Provider Services and Claims Quality to trend and evaluate Provider complaints and inquires, with the expectation of avoiding A/R file submissions.
- Research, review, and interpret existing contracts to discern any possible advantage for the company; may (re)negotiate contracts to provide favorable terms as well.
- Establish reserves based on A/R liability to minimize financial impact to the enterprise.
Qualifications:
- Bachelor's degree in Business Management or related; Master's degree preferred.
- Six Sigma / Project Management certification preferred.
- 10+ years of experience managing high volume HMO and/or PPO health insurance claims processing function across Commercial, Medicare and Medicaid segments. (required)
- Additional years of experience/specialized training may be considered in lieu of educational requirements. (required)
- Experience with an enterprisewide healthcare software/system (that includes automated claims processing, billing, care management and network management workflow, etc.), preferably FACETS. (required)
- Strong knowledge of contract requirements, provisions, SLAs, metrics, terms, and other parameters that impact/measure overall performance and compliance; and the ability to negotiate contract terms. (required)
- Analytical skills with emphasis on generation and utilization of data to drive operational and financial performance. (required)
- Ability to identify, quantify, and analyze problems; and to develop, recommend, and implement solutions effectively. (required)
- Critical "endtoend" thinker and business problem solver who moves quickly and decisively. (required)
- Strong interpersonal, problem solving and project/time management skills. (required)
- Excellent communication skills (verbal, written, interpersonal) with all internal/external audiences. (required)
- Ability to effectively develop and deliver presentations to all levels within and outside of Emblem. (required)
- Ability to work in a complex, rapidly evolving environment with multiple internal and external entities and boundaries. (required)
- Job Type: Standard
- Schedule: Fulltime
- Employee Status: Regular
- Requisition ID:
- Hiring Range: $150,000$280,000
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