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Sr Network Provider Advocate

Job Category: Delivery System Management

Location: New York, NY, United States

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Job Description

Description

The Senior Network Provider Advocate is responsible for managing both resolution of escalated claims projects and successfully addressing root cause issues that generate escalated claims projects. This role will serve as an internal resource for the DSE team regarding claims related matters received through the established work flow. The Advocate is responsible for providing the feedback and claims reprocessing details that will be used externally to close out open claims issues. Additionally, this role will manage both small and large scale claims projects and initiate root cause resolution of systemic issues that contribute to reprocessing projects. The role is cross functional and works with Claims Operations, Benefits, Network and Provider Operations and Reimbursement to successfully resolve underlying issues that contribute to claims reprocessing.

  • Conducts claims root cause analysis and facilitates resolution
  • Submits qualifying claims projects and tracks progress to completion
  • Initiates request for reprocessing summaries from OCS and provides final reports to Account Managers.
  • Conducts Q/A to ensure requested project was fully completed
  • Works as a root cause resolution SME to the Network team for assigned providers
  • Reports issues to internal business areas for investigation and if needed root cause resolution
  • Initiates claims sweeps as needed for root cause issues that impact more than one provider
  • Works as a liaison with CSG for assigned hospitals to address aging
  • Additional duties as assigned.

Minimum Qualifications:

  •  (Understanding of various payment methodologies (Ex. Capitation, APR DRG, MS DRG, APGs, APCs, RBRVS, Per Diems)
  • Working within one or more of the following areas:  Managed Care, Network Management, Claims, Patient Accounts,
  • Experience with managing Accounts Receivable projects
  • Experience with working with internal business partners to resolve systemic issues.
  • Summarizing results of completed Claims projects
  • MS Excel
  • HSD/GED/HSED
  • Critical thinking skills

Preferred Qualifications:

  • Root Cause resolution
  • Cross functional experience in working as a liaison to internal business partners
  • Familiar with reimbursement methodologies for Ancillary and Behavioral Health Services (Ex. SNF, Dialysis, Home Care, Urgent Care, Behavioral Health specialties)

Compliance & Regulatory Responsibilities: N|A

License/Certification: N|A

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

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