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Claims Relationship Representative

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MetroPlus Health PlanYonkers, NY
  • Care. MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care.
  • We believe that Health care is a right, not a privilege.
  • If you have compassion and a collaborative spirit, work with us.
  • You can come to work being proud of what you do every day.
  • About NYC Health + Hospitals
  • MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.
  • As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus' network includes over 27,000 primary care providers, specialists and participating clinics.
  • For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
  • This Relationship Representative is responsible for the accurate and timely response to claims inquiries received from providers and internal MetroPlus departments.
  • Incumbent will provide support regarding the adjudication and adjustment of claims for the BPO Products at MetroPlus Health Plan. The incumbent works closely Provider Relations, Medical Management, Member Services and DST BPO.
  • Act as a key liaison and claims liaison for provider inquiries and problem resolution via telephone/correspondence.
  • Respond to claim inquiries from providers including physicians, clinical staff, and site administrators.
  • Coordinate and track appropriate problem resolution activities with plan personnel in other departments (i.e. Member Service, DST BPO and Utilization Management) Manage and ensure appropriate follow-up and closure for all inquiries
  • Conduct special projects /studies; participates in various work groups upon request.
  • Ensure adherence to all Claims Processing Legislative and Regulatory requirements.
  • External contacts may include written and/or verbal contacts with hospitals and physicians.
  • Assist with Medicare claim inquires as needed.
  • Other duties as assigned by Management.
  • High School Diploma or General Education degree required.
  • Bachelor's degree preferred.
  • A minimum of one year of Customer Service experience and at least (3) years of claims insurance experience.
  • Billing/coding experience is strongly preferred.
  • Knowledge of Federal and state regulations and laws impacting the New York Health Benefit Exchange and the Patient Protection and Affordable Care Act a plus.
  • Knowledge of Claims Processing/Adjustment protocols and payment.
  • Schemes including CMS claims processing guidelines.
  • Knowledge of managed care, health care systems, and Medicare valuable and legal/regulatory requirements preferred.
  • Knowledge of customer service principles and practices.
  • Strong listening, verbal, written, research, analytical problem-solving skills required.
  • Strong ability to manage multiple assignments simultaneously.
  • Basic competency in word processing, spreadsheets, database and presentation software required.
  • A satisfactory combination of education, training and experience.
  • Ability to communicate in a professional manner.
  • Adept at managing complex and at times emotional/irate calls.
  • Integrity and Trust Customer Focus Functional/Technical Skills Written/Oral Communication
  • Associated topics: claim adjuster, claim examiner, damage, fraud, insurance, insurance investigator, investigate, investigation, liability, title examiner

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