Provider Relations/Network Services Coordinator - SHCN
Position Purpose: The Network Services Coordinator has daily interaction with internal departments to coordinate the daily release of pended claims, update provider demographics, review and resolve Electronic Data Interchange (EDI) issues affecting claims, enroll providers in EFT, and enroll providers in ERA. Coordinate the submission, follow up, and resolution of claim projects in coordination with Network Services Representatives and the Reimbursement Services Department. Perform a wide variety of other department functions and duties as assigned.
This position requires knowledge of all elements of Steward Health Choice plans processes and policies to enable and promote completion of projects, tasks and or assignments. Sound and objective decision making must be exercised in all interactions within Network Operations, internal departments and provider/facility groups as requested or needed.
Review claim reports on a daily basis and ensure that company systems are updated so that pended claims can be released for processing. Effectively communicate with Member Services and Reimbursement Services department staff to ensure that claims are processed in an accurate manner.
· Download pended claim reports on a daily basis and enter provider demographic updates into company systems so that pended claims can be processed.
· Effectively collaborate with Reimbursement Services to ensure that pended claims are appropriately paid or denied
Coordinate claim resolution requests with the Network Services Coordinators.
· Prepare claims resolution spreadsheets for submission to Reimbursement Services.
· Track progress of all submissions to ensure that claims are adjusted accurately and in a timely manner.
· Provide status updates to Network Services Coordinators so they can notify providers.
· Follow up with Reimbursement Services with claims are adjusted either inaccurately or in an untimely manner
Various other duties as assigned.
· Take minutes in weekly departmental meetings
· Assist Network Services Representatives to prepare contracts when they are outside the office.
· Using pended claim reports, Identify providers who need to be credentialed or loaded into our systems and then communicate these requests to the PDM Coordinator for processing.
· Perform a wide variety of other functions and duties as assigned.
Equal Opportunity Employer Minorities/Women/Veterans/Disabled
· High school Diploma/GED is required
· College degree is preferred
Years of Experience:
· A minimum of two years of health plan experience is preferred
Work Related Experience:
· Knowledge of Medicaid and Medicare Programs is preferred
· Organizational skills
· Strong presentation and oral and written communication skills
· Proficient ability to use Microsoft Office products include Excel and Word
· Ability to negotiate and implement provider contracts
· Strong customer service skills and techniques
· Ability to plan and organize