Provider Resolution Analyst

October 10

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NJM Insurance Group

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Auto Insurance • Workers'​ Compensation Insurance • Homeowners Insurance • Commercial Auto Insurance • Renters Insurance

1001 - 5000

Description

• Responsible for coordinating the resolution of claims issues • Actively researching and analyzing systems and processes that span across multiple operational areas • Identifying issues with larger impact to members and/or providers • Ensures correct application of Medicaid Benefits as specified by regulations • Completes investigation and root cause analysis of complex claim issues • Facilitates resolution through proper channels by working with multiple operational areas • Analyzes systems and processes involved in member enrollment, Medicaid State Files, provider information management, benefits configuration and/or claims processing • Performs extensive research, analysis and logical conclusions of paper and electronic claims to resolve disputes by providers/members • Conducts all necessary follow-up with internal departments within regulatory timeframes • Escalates complex issues identified to Provider Resolution Analyst II • Assists in identifying dependencies that may impact other members, or providers • Identifies appropriate course of action for resolution and creates appropriate issue tracking request

Requirements

• High School Diploma/GED required • Requires 2+ years claims experience • Facets experience preferred, but other claims experience considered • CPT/HCPC and ICD9 coding, procedures and guidelines knowledge preferred • Strong Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms and CPT Coding • Prefers knowledge of health care industry policies and procedures, knowledge of Medicaid or other Governmental Health Program • Prefers knowledge of FACETS or other Medicaid/commercial claims processing platform; knowledge of SharePoint system, Document Management System (DMS) • Prefers excellent presentation, oral and written communication skills • Requires customer service focus and a problem solving aptitude • Requires strong organizational and analytical skills • Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Outlook • Intermediate Ability to work as part of a team

Benefits

• Comprehensive health benefits (Medical/Dental/Vision) • Retirement Plans • Generous PTO • Incentive Plans • Wellness Programs • Paid Volunteer Time Off • Tuition Reimbursement