Gateway Health Plan
Job Description :
This job will adhere to all state guidelines for the position and work to support providers and Gateway Health in ensuring claims education is appropriately conducted for both par and non-par providers. Duties include, but not limited, to development of an annual plan for provider education training using electronic, in person and other sources to disseminate information and increase claims filing accuracy. Detailed understanding of coding guidance from CMS and DHS is essential. The incumbent will lead the process for collaboratively assisting in resolution of claims issues and working with Provider Relations, Payment Integrity, Claims, Customer Service and as required work directly with providers.
Oversee all claims education activities regarding the following details:
- Data collection on provider concerns from Customer Service, Appeals and Grievances, and interactions with key staff such as Provider Account Liaisons and Payment Integrity to determine any trends or providers who appear to be in need of additional education.
- Development of reporting for executive and senior leaders on claims education and resolution of issues.
- Monthly review of claims denials and those pending, to identify potential training needs.
- Identification of appropriate staff to engage and provide education
Development of an annual plan for provider claims education training using electronic, in person and other sources to disseminate information and increase claims filing accuracy. The plan should consider at least the following:
- New coding guidance provided CMS and DHS
- Targeted areas where review of claims history, concerns from providers or internal issues show additional education is required either in a group or individual setting.
- Updates from DHS/CMS require additional education either in group or individual settings.
- Overall direction for claims education in for all enterprise Lines of Business (LOBs) and geographical regions.
Development of claims education and coordination with key leaders to align existing internal resources (Provider Account Liaisons, Customer Service Staff, claims staff and others.) This should include at least the following:
- Appropriate assignment of roles by department and key
- Coordination of any claims education and claim issues where additional training is required.
- Development of SLAs for each department
- Reporting on all educational activities
- Development and implementation of tools, support services and other areas to improve efficiency.
Assist in resolution of claims issues working with Provider Relations, Payment Integrity, Claims, Customer Service and as required work directly with providers.
- Organize data regarding Success Metrics:
- Compliance with all state requirements for training
- Claims issues resolved appropriately within 30 days
- Reduction in state complaints
- Quarterly details of reduction in pending and denied claims
Other duties as required
- 5 years with medical coding, preferably at a managed care plan, hospital or provider's office
- 5 years of Medicaid and Medicare billing and claims
LICENSES or CERTIFICATIONS
- Certified Professional Coder (CPC)
- Superior communication ability both written and verbal
- Experience with SAS, Excel, Word and PowerPoint
- Experience with Electronic Medical Records and Claim payment and billing systems
Language (Other than English):
25% – 50%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
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