Position Summary:
The Billing Coordinator will follow up on unpaid claims utilizing monthly aging reports, filing appeals when appropriate to obtain maximum reimbursement. Process and monitor incoming payments and secure revenue by verifying and posting receipts in compliance with financial policies and procedures.
Essential Functions:
Collect, post, and manage patient account payments.Submit claims, investigate rejected claims to see why denial was issued.Submit appeals and reconsiderations to insurance.Review delinquent accounts and call for collection purposes. Escalate problem accounts to Manager to obtain payment.Process payments from insurance companies.Performs various collection actions including contacting patients by phone, correcting and resubmitting claims to third party payers.Handle information about patient treatment, diagnosis, and related procedures to ensure proper coding.Reports possible instances of fraud and abuse, if found.Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.Provide training in billing practices.In addition, all other duties assigned by the manager and/or supervisor.Education:
Certified High School Diploma or equivalent.Experience:
Minimum 3 years experience in medical billing with billing or medical coding certification. Knowledge of insurance guidelines. Experience in filing claim appeals with insurance companies to ensure maximum entitled reimbursementKnowledge:
Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Experience in CPT and ICD-10 coding; familiarity with medical terminology. Know several different coding systems, including Level 1 HCPCS and Level 2 HCPCS. Read LessPosition Summary:
The Health Professional 3/MCI its responsible for providing intensive follow-up to members exhibiting behavior or an environment that may predispose them to incompliance with medical treatment thus resulting in increased hospitalizations, costly treatments and/or worsening of their mental health status. Intensive follow-up may consist of telephonic follow-ups, home visits, integration and coordination care with community agencies and coordination depending on the necessity.
Essential Functions:
1. Conducts health risk assessment and identifies barriers that could affect or interfere with treatment effectiveness or adherence
2. Communicates with providers in the community regarding the consumer’s treatment needs and develops appropriate care plans for specialized needs of members
3. Follow-up by telephonic or/and community outreach and crisis intervention if necessary.
4. Provides chronic care management, empowerment, motivational interviewing, services coordination and other clinically based activities as assigned, based upon member’s severity of condition.
5. Educates the patient about their disease state as well as other health issues relating to their plan care.
6. Collaborates with other professionals to obtain better treatment results and overall care
7. Investigates, reviews and maintains data related to treatment, care and/or related services
8. Establish case discussions with Medical Consultant and/or Medical Director
9. Will represent the company in Court for cases under follow-up and prepare reports if necessary.
10. Documents all activities per APS policies and procedures.
11. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.
12. And all other duties assigned by the manager and/or supervisor.
Education:
· Bachelor’s Degree in a Behavioral Health field; Master’s Degree preferred.
· Current, unrestricted license to practice preferred.
Experience:
· Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.
Knowledge:
· Strong knowledge in behavior principles, chronic illnesses and disease management.
· Strong telephonic assessment and customer service skills.
· Knowledge in community based resources.
· Knowledge in clinical assessment and crisis intervention.
· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Read LessPosition Summary:
The Client Services Coordinator 2 / G&A provides outstanding customer service. This key individual communicates with a wide variety of external contacts including members, providers, facilities, as well as clinical and operational staff. The Client Services Coordinator assesses the needs of internal and external clients in a timely and efficient manner, thus resulting in optimum operational performance. The Client Services Coordinator 2 is fully dedicated to duties of the Quality Department. This employee is not responsible for conducting any UM review activities that require interpretation of clinical information.
Essential Functions:
Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. Recognizes customer needs to assist in a complaint, grievances, or appeals. Receives, prepares, and manages a complaint, grievances, or appeal file. Maintains a record of grievances and appeals utilizing various documentation operating systems. Conducts investigations to resolve complaints, grievances, and appeals. Maintains database by entering information related to the department. Sends letters to beneficiaries and facilities when the regulations are applicable. Monitors and complies with the period to send notifications to the beneficiaries and the facility. Use of clinical data is limited to: Performance of review of service request for completeness of information; Collection and transfer of non-clinical data; and Acquisition of structured clinical data; and Activities that do not require evaluation or interpretation of clinical information. In addition, all other duties assigned by the manager and/or supervisor.Education:
High School Diploma required. Bachelor’s degree preferredExperience:
Minimum 2 years of experience in a customer service position.Knowledge: ·
Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Read LessPosition Summary:
The Health Professional 1-Pharmacy Call Center Representative manages telephone calls from pharmacies and providers related to pharmacy benefits, authorization requests, drug use review, among others, to ensure that claims are correctly and timely adjudicated.
Essential Functions:
1. Answers and manages telephone calls from pharmacies and providers in a timely, confidential and courteous manner.
2. Documents calls and/or drug requests with complete follow-up history of the patient through electronic records.
3. Provides orientation to pharmacies regarding pharmacy benefits.
4. Performs system overrides (e.g., prior authorization) on the PBM claims processing system to ensure that claims are
correctly adjudicated.
5. Assists pharmacies claim processing.
6. Assist in the training of pharmacy representatives.
7. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.
8. In addition, all other duties assigned by the manager and/or supervisor.
Education:
Pharmacy Technician Course of accredited school.Possess an active professional unrestricted Pharmacy Technician License in good standing to practice in Puerto RicoExperience:
· Minimum 2 years’ experience in retail pharmacy preferred.
Knowledge:
· Basic knowledge of physical and mental pharmacotherapies, in order to make accurate assessments of clinical cases.
· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Read LessPosition Summary:
The Health Professional 1 provides telephonic customer service and timely resolves inquiries regarding patient care, eligibility, benefits, and claims, among others. This key individual provides follow up for patients to assure continuity of care and efficiency of overall services. This employee is not responsible for conducting any UM review activities that require interpretation of clinical information.
Essential Functions:
1. Verifies patient eligibility and arranges appointments when needed.
2. Provides assistance via verbal and written correspondence for subscribers, patients-relatives, providers, account
representatives, among others.
3. Authorizes initial patient care per the company’s policies and procedures.
4. Performs telephonic non-clinical referrals for customers. Performs data entry and timely documents of all calls.
5. Conducts investigation and research to resolve customer inquiries, claims and questions.
6. Performs follow up calls to ensure effective patient care and provision of services. (10%)
7. Communicates actively with internal staff such as Care Managers, Supervisors and other department managers.
8. Use of clinical data is limited to: Performance of review of service request for completeness of information; Collection and transfer of non-clinical data; and Acquisition of structured clinical data; and Activities that do not require evaluation or interpretation of clinical information.
9. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.
10. In addition, all other duties assigned by the manager and/or supervisor.
Education:
· Bachelor’s Degree in Behavioral Health or related field preferred.
Experience:
· Minimum 2 years of experience in customer service in a behavioral health or managed care environment preferred.
Knowledge:
· Knowledge and ability to interpret benefit, account and claim information.
· Proficient in data entry.
· Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
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