Administer operational activities such as prepare and maintain records associated with premium collection, enrollment data and reconciliations of cash receipts. Collect and verify census enrollments and apply cash receipts in accordance with established guidelines and procedures. Follow up/investigate census and premium discrepancies, request additional information from administrators, and generat

Responsible for completing cost report reopenings within established timeframes and ensuring that the quality of our work meets CMS expectations. Reopenings include review of various provider types and issues related to the Medicare cost report. Description 40% Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities

Responsible for auditing group (small/large/complex) accounts to ensure premium payments and/or reimbursements are processed/reported in timely/accurate manner. Audits subscriber accounts to ensure premium payments are within grace period. Resolves billing/payment problems, adjudicates insufficient and/or incorrect payments back to subscribers. May serve as primary contact with group regarding mon

Establishes and maintains positive relationships with network hospitals, physician and/or dental practices, and their representatives. Serves as point of contact for provider problems/issues. Responds to non routine or difficult problems/issues related to network contracts, reimbursement methodologies, benefit structure, medical policies, administrative policies, etc. Determines underlying cause(s

Responsible for moderately complex accounting activities relating to the maintenance of a complete and accurate general ledger and/or the resultant managerial reports and/or financial statements. Description 30% Reconciles assigned general ledger accounts of routine to moderate complexity. Initiates and/or processes journal entries into various accounts. Performs reviews of various systems activ

Oversees the accurate processing of claims that have been deferred for medical necessity review. Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations. Identifies and implements process improvement opportunities. Description 70% Manages the medical review process. Maintains a well trained staff. Develops/implements medical review strategy wit

Reviews and adjudicates complex or specialty claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Assists in training or mentoring new staff members. Description 70% Examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines. Enters claims into the claim system a

Responsible for submitting stop loss claim packets and responding to any requests for additional information. Additionally, the claims must be tracked and monitored. Complex analysis is performed and queries are generated to file and validate the claim submissions. Description 25% Prepare and file 50% and 100% stop loss claim packets. Run queries, compile eligibility data and submit claim packet

Provides prompt, accurate, thorough and courteous responses to all customer inquiries. Performs research as needed to resolve inquiries. Description 65% Ensures effective customer relations by responding accurately, timely and courteously to telephone, written, web, or walk in inquiries. Accurately documents inquiries. 15% Initiates or processes adjustments or performs other research as needed t

Develops test plans and test matrices, conducts testing and reports test results for system changes. Coordinates implementation and debugging of new software ensuring that the new or modified applications work in the production environment and meet the expectations of customers. Researches and defines system production issues and works with Information Systems on both short term and long term reso

Monitor and/or reconcile assigned general ledger accounts of a complex nature, process complex accounting activity, resolve variances, and/or document procedures to ensure accuracy of accounting information and/or financial reports, and/or compliance with established rules and/or regulations. Provide functional advice and/or training to less experienced accountants. Description 30% Prepares dail

Responsible for auditing group (small/large/complex) accounts to ensure premium payments and/or reimbursements are processed/reported in timely/accurate manner. Audits subscriber accounts to ensure premium payments are within grace period. Resolves billing/payment problems, adjudicates insufficient and/or incorrect payments back to subscribers. May serve as primary contact with group regarding mon

Functions as work leader for customer service units. Assists with escalated and complex issues. Description 60% Serves as an information source for both internal and external customers by answering complex customer service inquiries via telephone, e mail, and/or web inquiries. Inquiries are non routine and require deviation from standard screens, scripts, and procedures. 40% Ensures efficient de

Responsible for establishing and maintaining certification and/or preparation, review and/or maintenance of healthcare provider files in support of provider directories, accurate/timely claims adjudication, and provider billing. Description 50% Verifies necessary/needed information (written notifications, faxes, emails, or telephone contacts) and/or establishes certification of healthcare servic

Provides first and second level technical support to a variety of customers comprising the submitter community, as well as basic internal support via analysis and research into EDI related issues as required by business contracts. Description 60% Provides quality/timely internal/external customer technical support/service for variety of insurance contracts as assigned. This encompasses, but is