Processes Professional and Facility claims for payment in accordance with members Certificate of Coverage, established medical policies and procedures, and plan benefit interpretation while maintaining a high level of confidentiality. Reviews claims to ensure compliance with proper billing standards and completeness of information. Obtains additional information from appr

Demonstrates commitment and behaviors aligned with the philosophy, mission, values, and vision of Network Health. Applies organizational, regulatory, and credentialing principles, policies, and procedures to the claims production process. Assists the Manager of Claims Production and/or Manager of Claims Recovery with regulatory reporting and compliance audits, including D

Validation testing of new data sources to existing with reporting identifying variances in written communication User testing of portal functionality and data to existing source system results Correction of any data integrity issues Development of reconciliation exhibits to show balance sheet figures are used consistently across various financial calculations Assist in cr

Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health Appropriately apply all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies Employment Law partner with Human Resources to offer trainings and reminders on best practices regarding the FMLA, ADA, etc. Contr

Develops, maintains and regularly reviews department policies, processes and desk procedures to ensure regulatory compliance, maximum efficiencies, and alignment with industry best practice; identifies gaps and works with department leadership and/or trainers to facilitate implementation of improved processes. Daily supervision of staff and department operations Establish

Performs data entry, claim, and call monitoring activities and scores performance according to set criteria and timelines Perform other operational audits and scores performance according to set criteria and timelines. Trends monitoring results and provides feedback to the Manager of Quality Assurance Compiles results into meaningful, actionable reports with recommendatio

Perform end to end delivery of data interfaces in various stages of the Enterprise Data Warehouse in accordance with professional standards and industry best practice Perform all phases of the development lifecycle including solution design, creation of acceptance criteria, implementation, technical documentation, development and execution of test cases, performance monit

Fully reviews all appeals and grievances assigned, to determine appropriate supporting documentation needed to address the issue being appealed. Compile supporting documentation for appeal process. Resolve any discrepancies in information with internal departments or providers as necessary. Communicate with members regarding status of appeals that have been submitted. Per

Develop, update and coordinate work associated with the operational annual product refresh and benefit implementation. Collaborate with various departments on deliverables to ensure they are submitted timely and accurately to avoid financial penalties. Act as a liaison between product development department and numerous business owners from different functional areas of t

Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health Appropriately apply all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies Process enrollment applications, changes and terminations for all products received. Responsible for handling incoming and outgoin

Demonstrate commitment and behavior aligned with the philosophy, mission, values, and vision of Network Health Appropriately apply all organizational and regulatory principles, procedures, requirements, regulations, and policies Performs data entry, claim, and enrollment monitoring activities and scores performance according to set criteria and timelines. Compiles results

Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health Appropriately apply all organizational and regulatory principles, procedures, requirements, regulations, and policies Supports and regularly reviews department policy and procedure documents to ensure regulatory compliance, operational efficiency, and alignment wi

Assist the CMO with monitoring availability, appropriateness, and necessity of care rendered by participating providers and by out of plan providers Participate in oversight and clinical decision making of the UM program, including but not limited to rendering denial determinations for services not considered medically necessary or experimental/investigation/unproven in a

Develop, test, and maintain data interfaces between business data sources in accordance with departmental and professional standards Perform analysis, design, coding, and maintenance of data imports and extracts Develop, test, and implement data change scripts to support the claims processing system Consult with Business Quality Analysts, Developers, Engineers, DBAs, key

Manages provider and/or supplemental vendor operations concerns and issues Ability to craft solutions through understanding of provider and/or supplemental vendor needs and leveraging of company resources Exceptional listening and communication skills Collaborates well with other internal departments Ability to build and maintain effective working relationships Strong org