Provider Claims Representative

Healthfirst is a not-for-profit managed care organization with a unique hospital-managed business model'allowing us to successfully deliver state and federally subsidized quality healthcare to more than 480,000 members through a network of close to 20,000 physicians and specialists.Operating in the five boroughs of New York City, Long Island and Westchester County in New York, and in Bergen, Essex, Hudson, Passaic and Union counties in New Jersey, Healthfirst has partnered with our participating hospitals to develop a solid and effective approach to meeting the ever-changing needs of the medically underserved. What's more, strong relationships with community-based organizations, schools, advocacy groups, local politicians, hospitals, governmental agencies and businesses allow Healthfirst to stay abreast of healthcare needs within the communities we serve and develop programs to meet them. Everyone at Healthfirst is committed to our members. Our Quality Improvement and Medical Management departments continue to develop effective and efficient treatment programs that maximize safe clinical practices and enhance service delivery while our participating providers ensure that members receive the highest possible quality care. As result, Healthfirst is the #1 Medicaid plan in New York State in terms of clinical quality. ' Respond to on-line telephone inquiries regarding plan benefits, claim payment, and provider information.' Assist Correspondence staff, as required, concerning written inquiries for all products. ' Evaluate claim processed and reprocesses it if erroneously handled.' Provide ongoing education, support, and assistance to the Provider Network in regards to plan benefits and procedural policies.' Identify trends resulting from provider telephone inquiries and recommend solutions to reduce volume of phone inquiries. ' Fact finds problem solves, and troubleshoots potential, and existing issues.' Operate telephone/ACD system.' Forward issues/queries to the appropriate HealthFirst department. Follow-up on any 'open' or 'pending' issues/queries. ' Meet departmental quality and production standards.' Perform other duties assigned by Management. ' Excellent communication skills (written, oral)' Demonstrate ability to handle multiple product lines' Experienced Claim Examiner professional ' Extensive knowledge of DRG, ICD-9, and CPT-4 coding experience ' Working knowledge of medical terminology' Familiarity with Medicaid, Medicare, and Commercial regulations' Excellent organization problem solving, and analytical skills' Ability to review the accuracy of claim payments, identify system flaws, and recommend areas for improvement' Ability to interpret instructions, and prioritize work assignmentsExperience:' Must have a high school diploma. Two years of college, or equivalent combination of education and experience in a managed healthcare environment. ' Knowledge of managed care claims processing.