BH Claims Service Representative

Position Overview :

This position is responsible for the accurate and timely response to Behavioral Health claim inquiries received from external entities and internal MetroPlusHealth departments. Incumbent provides support regarding the adjudication

and adjustment of claims for the multiple lines of business. Inquiries are received via multiple intake-channels, including Salesforce, email, A WD and fax. The incumbent works closely with Provider Network Operations,

Medical Management, Customer Experience Strategy, BH Operations and the Claims Processing unit.

Scope of Role & Responsibilities :

Research and analyze BH claims inquiries and adjustment requests to determine payment accuracy.

Adjust / adjudicate as needed using multiple systems and platforms.

Ensure the proper payment guidelines are applied to each claim by using the appropriate tools, processes, and procedures (e.g., claims processing P&P's, job aids & desk level procedures, reconsideration / appeals procedures, state mandates, CMS / Medicare / Medicaid / OMH guidelines, benefit plans, etc.).

Coordinate, follow-up and track appropriate problem resolution activities with all appropriate staff to ensure timely resolution.

Advise business partners of findings outcome when their input is needed to help fix the issue.

Work with the management team to stay updated on claims processing criteria, regulatory updates, new benefits and / or products and be informed of any changes in company policies.

Impact the company's bottom line by problem solving and turning frustrated customers into contented customers.

Participate in 'special' projects as required.

Required Education, Training & Professional Experience :

High School Degree or evidence of having passed a High School Equivalency Program required. Associate degree preferred.

Four (4) plus years' experience of Behavioral health claims processing experience required.

Experience with claims processing systems / applications.

Experience with Customer Relationship Management (CRM) applications.

Experience in PowerSTEPP, HealthRules Payer and Salesforce a plus.

Professional Competencies :

Integrity and Trust

Customer Focus

Strong analytical skills

Functional / Technical skills

Written / Oral Communication

Ability to consistently produce quality work

Able to work independently and exercise good judgment

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