PAR - Provider Inquiry Representative

Job Description - PAR - Provider Inquiry Representative I (2400650)

This is a hybrid role and requires employees to be in our Toledo office 3 days a week.

Investigates and resolves all inquiries (telephonic, written and faxed) from participating and non-participating hospitals, primary and specialty care physicians, ancillary and allied health care professionals regarding claim status, claim payment, authorization confirmations, facilitations documenting, member eligibility, and benefit eligibility. Meet specific telephone and contact service form performance standards as indicated in the department?s quality indicators. Supports the overall operations within the Provider Relations Department.

ESSENTIAL FUNCTIONS:
? Communicates providers appropriate claim status, claims filing requirements including, but not limited to, use of proper billing forms, coding requirements, timely filing limitations, and appeal processes.
? Communicates providers accurate eligibility and benefits to ensure our members receive the proper services. Assists providers with pre-authorization for medical treatment.
? Responses to member inquiries, contacts providers in a timely manner to problem solve issues related to inappropriate billings, assures the contractual obligations of the providers are met.
? Identifies claims that require adjustments. Forwards adjustment requests in a prompt and accurate manner to the Claims Department for adjudication.
? Facilitates resolution of provider escalated or sensitive situations, offers a positive customer service experience, and ensures provider satisfaction.
? Provides support to internal customers (Member Services, Utilization/Case Management, Provider Relations, etc.) regarding claim/member billing issues to ensure member/provider satisfaction and meets regulatory compliance standards.
? Performs other duties as assigned.

Education and Experience:
? Associates degree in business administration or related field or equivalent combination of training and experience.
? 2 years' experience in one or more of the following areas: HMO/PPO customer service, claims submission and/or processing medical terminology, medical billing, CPT, HCPCs, ICD-10, and DRG coding.
? Demonstrated planning, organizational, analytic, and problem-solving skills.
? Ability to handle multiple priorities.
? Basic PC navigation and MS Office skills preferred.
? Knowledge of standard office procedures and equipment.

About Medical Mutual:

Medical Mutual?s status as a mutual company means we are owned by our policyholders, not stockholders, so we don?t answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
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