Professionly in the health care industry with 6+ years of experience. Highly motivated indivudial balancing multiple responsibilities. Bringing innovated ideas.
• Leadership and agility
• Collaboration & Teamwork
• Time Management.
• Ability to Work Under Pressure.
• Decision Making.
• Conflict Resolution.
• Attention to detail
Responsible for organizing and submitting roster, vendor file or any applicable data worthy of upload into the eVIPS System. Tasked with working non par provider edits in the QNXT system as well as linking participating providers to their appropriate pay-to and contract configuration in the QNXT system based on updates received from Provider Specialists or NDM within the eVIPS platform.
Involved in the implementation of DIU, Altrex, and eVIPS system. Worked closely with IT attending weekly meetings. Coming up with innovative ideas that were implemented. Integration testing the system weekly making sure there are no major issues or claims impact.
• Organization of vendor file data, rosters/reconciliations, various bulk change information & provider terminations
• Submission of Vendor File Data, Rosters/Reconciliations, Various Upload information & Provider Terminations in the eVIPS System
• Determine completeness of forms prior to entry. Research any misleading or missing data fields and escalate any unresolved issues to Manager as appropriate
• Creation of net new HCO & Plans in the eVIPS system based on change controls
• Work with various departments on any identified discrepancies
• Research and Update all provider NPI, Pay-to and associated logic linking in the QNXT application as applicable
• Responsible for ensuring edits are completed within applicable SLA on a timely basis
• Fully support internal audits and respond timely to any resulting action plans
• Explore Process Improvement opportunities as well as mentor new and current team members if needed
• Expedite implementation delays and escalate issues to management as appropriate
• Partaking in miscellaneous projects at Fallon Health
• Participate in research and testing of system application accuracy to resolve processing problems
• Quality Control on all implemented Data and ensuring that all provider entry is entered into the core processing system within 30 days of receipt
• Responsible for researching and resolving provider call tracking cases within defined timelines.
• Responsible for working all assigned provider integrity reports accurately and timely.
Worked within the Configuration and Support department to ensure all new and existing sponsor and provider information is entered into the QNXT system and all other related databases in a timely and accurate manner. Also ensures all Sponsor related materials are created and sent to appropriate membership and based off of the materials configures the appropriate benefits within the PCS application. Works to ensure that all error, data integrity and various reports are processed effectively pertaining to all system applications used.
Configuration work responsible for impact the end result of our health plans as well as the quality of our claims operations, customer care operations, and cost containment & recovery operations. With a strong dedication to excellent quality of work, ensures that our members and providers have a positive experience as part of the Fallon Health network, and that we pay claims correctly and on time, avoiding fines and extra costs. When a health plan operates as expected by our members and providers leads to a great healthcare experience and the best possible outcomes.
Ensures payment resolution for identified claim overpayment recoveries in a timely, accurate, and efficient manner. Process complex claims and ensure correct payment of authorized claims following established protocols. Ensure compliance with contract administration, and service level requirements through claim reviews and client appeals. Work with other departments, project teams, vendors and committees as needed to resolve issues and contribute to policy and procedural improvements
• Complied with all department and company guidelines including all applicable laws and regulations.
• Worked with internal and external partners to educate/implement corrective actions and recover overpayments.
• Serve as a subject matter expert and provide peer support in a mentoring or collaborative capacity in the office environment, whether it be training or answering of questions, as deemed appropriate by management.
Claim Savings Duties:
• Responsible for claim processing related to claim editing software
• Testing and documentation of claim editing software functionality
• Root cause analysis of claim editing issues
• Monitor and identify billing areas for review and research.
Facility/Provider Audits duties:
• Provide monthly claims file to vendors
• Manage the facility/provider audit process
• Monitor and track audit activity
• Handle provider appeal process
• Report routinely to manager on results
Negative/Credit Balance and Refund Checks duties:
• Analyze weekly negative balance reports.
• Notify providers of negative balance status.
• Work with Collection Agency and Credit Balance vendors
• Monitor, track and process refund checks
• Recommend Negative Balance Write-offs
•Resolved a high volume of claims edits for all lines of business.
•Thorough understanding of authorizations, benefits, contracts, enrollment and fee schedules.
•Price claims using external vendor processing systems and manually apply rates in the core system.
•Resolved complex and high dollar claims.
•Ensured accuracy and timeliness of claims processing to minimize late payment interest penalties and ensure compliance with established guidelines.
•Evaluated all Customer Service cases related to pended claims.
•Worked with teams inside and outside the department, and external customers as needed.
•Responsible for claims editing on claims due to data entry errors.
•Processed member reimbursement requests, including Part D and other prescription reimbursements in the core and external vendor processing systems.
•Claims entry and processing tasks as assigned.
•Evaluation and resolution of Customer Service cases related to reimbursement requests.
•Review and validation of requests for claim review and other claims documents.
•Served as a subject matter expert.
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