Knowledge of Medical Terminology
Knowledge of HIPAA
Provider Contracting & Credentialing
Knowledge of HMO
Knowledge of Medicare and Medicaid
Responsible for supporting the administrative functions of the provider networks and act as a resource for the network, department, and the clinician network liaisons.
Resolves provider issues by interfacing with HCP central departments (Contracting, Eligibility, Claims and Finance). Follows up with Payor Contracting department on status of clinicians being added, terminated as well as open / closed panel status based on health plan website and submitted information.
Serves as a point of contact to central departments for issues related to the network, communicates relevant information from the central departments to the network and provides communications and documents upon request
Makes outreach and follow up phone calls to physician offices related to specific initiatives or meetings
Completes Notice of Changes and Preferred Provider Lists ensuring information on these forms are inputted into the appropriate systems
Attends and helps prepare adhoc meetings, takes minutes for specialty JOC meetings
Prepares benefit flyers for primary care physicians with health plan ID numbers.
Handles receiving, controlling, and processing of enrollment, disenrollment, and other types of enrollment transactions on behalf of Medicare beneficiaries ·
Responds to member benefits and eligibility inquiries over the phone or in person · Reconciles errors on capitation report and all discrepancies from CMS Daily Transaction Report (TRR)
Mails enrollment and disenrollment letters and ID cards to members in accordance with CMS requirements
Coordinates new provider or medical group contracts between sales representatives and provider data management
Maintains and updates data on all active brokers for commission reporting
Trains and supervises enrollment staff and member services
General office duties and administrative support
Spokesperson for the American Cancer Society in the “Fashionably Aware Fashion Bazaar”
Placed high-volume outbound phone calls to recruit potential participants of the Cancer Prevention Study (CPS-3) nationwide
Processing member applications
Maintaining member databases
Reviewing and summarizing publications
Providing research and administrative assistance to various projects
Participating in weekly staff meetings
Answering phone calls, data entry, filing, faxing, and mailing
Softwares: Microsoft Office Suite, CLAS V.0, MHC 23.1, Sigmund, InfoCrossing/Wipro Languages: Filipino, English, basic Spanish
Affiliations: CSULB Healthcare Student Forum, Medical Terminology, HIPAA
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