Provider Relations Specialist

SUMMARY: Provider Relations Specialist I Responsible for servicing internal and external customers who contact AF Group via the ACD phone line.

Responsible for providing quality, consistent and accurate medical payment information to internal and external customers.

Provider Relations Specialist II Responsible for analyzing billings including outpatient hospital and multiple surgeries by utilizing our Medical Bill Review (MBR) software and reference library to determine appropriateness of codes and excessive charges.

Responsible for making coding determinations according to state rules and regulations.

PRIMARY RESPONSIBILITIES: PRIMARY RESPONSIBILITIES: Provider Relations Specialist I

• Utilizes ACD phone lines to manage incoming calls and inquiries.
• Provides high level of customer service for all internal or external customers thru telephonic, email and fax.
• Demonstrates dependable work ethic.
• Manages confidential client information with discretion and good judgement in accordance with department and company guidelines.
• Identifies problems, provides solutions and resolves promptly, escalating more complex problems appropriately.
• Responds to written or verbal provider inquiries relating to our bill review analysis.
• Analyzes problems using problem solving methodology skills to determine root cause; communicates and implements solutions.
• Types, photocopies, faxes as necessary.
• Create reconsiderations for processing. Additional responsibilities of Provider Relations Specialist II
• Responsible for performing technical review of more complex medical bills, including but not limited to modifiers, anesthesia, & psychiatric.
• Responsible for analyzing complex billings for multi-state Workers Compensation medical claims to determine appropriateness of services billed.
• Responsible for making bill review processing determination according to rules and regulations and/or third-party partner.
• Evaluates medical bills and corresponding EOR’s for accuracy and compliance with state mandate fee schedule(s) and our business rules and guidelines.
• Reviews inpatient hospital, outpatient hospital, and multiple surgery billings.
• Reviews, analyzes, adjusts and releases queued bills in an accurate and timely manner.
• Refers to reference library of fee schedules, CPT, ICD-CM, HCPCS, and other industry publication to support findings.