Health Insurance Specialist

Position Description: Health Insurance Specialist

Under the direction of the Independent Dispute Resolution Entity (IDRE) Project Manager or his/her designee, the Health Insurance Specialist applies critical thinking skills, IDRE program policies and regulatory guidance to analyze and adjudicate payment determination disputes between nonparticipating providers, nonparticipating emergency facilities or nonparticipating providers of air ambulance services and a group health plan. The Health Insurance Specialist reviews all documentation received from the involved parties in regard to their proposed payment amount and renders an independent determination, selecting one of the two proposed offers, based upon the credible facts presented. In addition to review, the Health Insurance Specialist completes all case related documentation and sends appropriate email notification as per the established workflow. They are also responsible for timely and accurate case specific data entry into the government portal.

Responsibilities:

• Understand and represent PRI's mission, vision, and values to all internal and external customers
• Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI management
• Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
• Proactively manages and coordinates activities to ensure timeliness of deliverables to exceed contractual obligations
• Interact with project team members in order to successfully fulfill contract obligations with the highest quality and in a timely manner meeting PRITM's ISO requirements
• Instills integrity throughout the organization via active participation in ISO requirements including but not limited to timely submission of Corrective Action Plans for all matters in which either PRI standards and/or corporate contract standards have not been met. Communicating outcomes to team members to ensure a positive, open, environment which mitigates risk and achieves a culture of Continuous Quality Improvement.
• Contributes to business development efforts for new sales and marketing to promote the business through professional communications, sound decisions and by exceeding all contract timeframes and deliverable requirements,
• Utilize project resources for research and reference verification
• Demonstrated skill and experience in handling a large workload with varying deliverable dates
• Flexible with assignments to meet contract performance metrics
• Participate in interdisciplinary collaboration with PRI staff, recognized teaming partners, and/or subcontractors
• Demonstrated skill and experience in the submission of timely, accurate deliverables
• Demonstrated experience and skills in excellent customer service
• Proven skill and experience in excellent oral and written communication spanning executives to the general public
• Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI
• Perform duties of Health Insurance Specialist to ensure contract metrics are met
• Perform duties of Eligibility Insurance Specialist
• Performs independent dispute resolution review and payment adjudication activities as needed
• Perform other duties as requested