Integrated Resources, Inc
Company Details

Provider Claims Service Centre

Job ID

: 24408

Location

: Houston, TX, USA

Salary

: Not Specified

Job Views

: 109

Posted

: 2 months ago

Job Description


Job Title: Provider Claims Service Centre

Job Location: Houston, TX

Job Duration: 7 Months (Extension possibility)

Job timings: Mon to Fri 8.00AM to 5.00PM

                          Training Shift 7.30AM to 4.00PM

 

Position Summary:

Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff. Documents and tracks contacts with members, providers and plan sponsors.

Duties:

  • Explains member's rights and responsibilities in accordance with contract.
  • Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system.
  • Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues.
  • Responds to requests received from Healthcare's Law Document Centre regarding litigation, lawsuits.
  • Handles extensive file review requests. Assists in preparation of complaint trend reports. Assists in compiling claim data for customer audits.
  • Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals.
  • Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
  • Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary.
  • Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.

 

Experience:

  • 2+ years' recent experience in a call centre production environment OR customer service experiences in a transaction-based environment with extensive inbound/outbound phone experience REQUIRED.
  • 1-year minimum experience with Medicaid/Medicare or Health Insurance also in high volume production environment
  • Provider Claims or Medical Billing experience
  • 2+ recent years in a High-Volume Call Centre experience.


Education:

  • High School Diploma or GED required. Associates degree in Business, Accounting or equivalent work experience preferred.

 



Employment Types

Contract - W2


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