JOB SUMMARY: Provider Research Coordinator is a position within the Community Health Choice Provider Call Center. The Provider Research Coordinator is primarily responsible for, but not limited to responding to incoming provider hotline inquiries as they relate to benefit and eligibility verification, claim status (with the ability to identify if a claim requires reconsideration), authorization status, and complaints, accurate documentation recording of all provider calls; effective follow-up of provider calls, as required; and proper electronic routing with effective documentation skills.
JOB SPECIFICATIONS AND CORE COMPETENCIES
- Interpret and explain health plan benefits, policies, procedures and functions to providers, medical groups, or representatives of provider offices.
- Review, analyze and process routine and more complex provider disputes, requiring a more in-depth understanding of appropriate payment or denial practices, benefits, policies and procedures, and contract interpretation.
- Identify claims processing issues that result in Provider Relations and work collaboratively with the Claims Processing Supervisors and the Claims Production Manager to correct.
- Ability to respond effectively and timely to inbound calls from provider offices regarding benefits and eligibility, claims processing status, and authorization status.
- Marginal Functions
- Maintains a professional behavior and exhibit excellent interpersonal skills
- Works collaboratively with coworkers to deliver member/provider services that meet or exceed member/provider expectations
Reports to Position Title: Director Customer Experience
Employees Supervised Titles: Supervisors
- Education/Specialized Training/Licensure: High school or equivalent; Associates preferred
- Associates and two years; or Four years in lieu of degree with relevant work experience.
- Experience to include Health Care/Plan with claims knowledge. Cross-functionality in Claims, Authorizations,
- Benefits and Eligibility.
- Microsoft Office (Word, Excel, Outlook)
Organizational Core Competencies: All employees are responsible for understanding and demonstrating Community Health Choice core competencies:
- Customer Focus , Sustainability
- Reliability and Dependability ,
- Employee Empowerment
- Honesty & Integrity Sustainability
- Achievement Orientation Sustainability
- Change Management Affordability
- Team Work Employee Empowerment
- Analytical Thinking
- Attention to Detail
- Diagnostic Information Gathering
- Writing /Composing, Medical Terminology , Above average verbal