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Form of workTEKsystems has partnered with a local healthcare company, looking to hire Health Insurance claim representatives
Qualifications:
- Fluent in Microsoft Office
- Professional Relations Experience
- Credentialing Experience
- Health Insurance Claims experience
Responsibilities:
- Credential and recredential providers and facilities in accordance with our client, NCQA, CMS, NYS Department of Health and all other regulatory agency guidelines.
- Review and prepare files including clean files, issues, and red flag files for our client's Credentials Committee.
- Prepare letters to providers and facilities for credentialing/recredentialing/registration decisions and updates including non-compliance.
- Review and Process Provider and Mid-Level Registrations in accordance with our client's policies and procedures including but not limited to License Verification, DEA review, and regulatory sanction checks.
- Work in conjunction with Professional Relations and Network Management on projects including but not limited to directory verification, access and availability, deficiencies, provider quality issues, etc. to update provider demographic information.
- Research and update provider data elements as identified in provider data clean-up projects.
- Perform outreach to providers and facilities for required data as needed.
- Maintain all provider and facility data in Macess, Cactus and Facets systems. Validate provider education, licensure, education and training, and perform mandated sanction checks such as Licensure, DEA or CDS Certificate, Board Certification if applicable, Medical or Professional education, Residency and Fellowship Training if applicable, Malpractice Insurance and History, Medicare sanctions and opt outs, Medicaid Management Information System (MMIS), National Practitioner Identification Number (NPI) through NPPES, Social Security Administration Death Master File through the National Technical Information Service (NTIS) database, and Clinical Privileges if applicable.
- Gather and verify Provider data using several sources including but not limited to CAQH.
- Manage provider demographic information to include all updates and provider-initiated changes.
- Review and maintain non-participating provider claims from Facets and Macess with focus on the provider record only. Load new providers and update existing provider records. Ensure all regulatory claim payment timeframes are met.
- Perform functions related to separation and termination of providers from our client's Network including but not limited to researching providers, mailing termination letters, updating our client's systems, and coordinating the member notification process.
- Perform Quality Control of identified provider data elements and primary source verification for new providers, provider changes, and provider separation/inactivation’s entered into our client's core systems as outlined by department procedures.
- All team members are expected to continuously evaluate processes, identify potential improvements, and help implement changes.
- Performs other duties as assigned.
We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.
The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
