TEMP BPO Senior Representative

Responsibilities

• Review written dispute requests from providers regarding denied or incorrect payments for both Professional and Institutional Claims, based on contractual and non-contractual arrangements.
• Interpret provider and health plan contracts to ensure accurate payment or denial of claims, adhering to terms of the provider contract and financial responsibilities outlined in the health plan contract, including RBRVS and Medicare guidelines for contracted and non-contracted providers.
• Adjust claims as appropriate, including calculating interest and penalties when applicable.
• Identify potential issues related to system configuration, benefits, eligibility, or authorizations that affect the Claims Department’s ability to process claims accurately; escalate these issues to the correct internal department with all necessary documentation to ensure system updates and follow up as needed.
• Plan and organize workload to ensure efficient and compliant resolution of issues.
• Communicate dispute outcomes to providers in writing using system-formatted letters, ensuring clarity and adherence to departmental guidelines.
• Request special check runs to ensure compliance.
• Monitor warning reports daily to maintain compliance.
• Conduct provider education calls based on the outcomes of Provider Dispute Resolutions (PDR).
• Document each dispute accurately in the Provider Dispute Database for reporting purposes, supporting management reports for internal and external customers as required by AB1455.
• Maintain minimum departmental standards for quality and quantity of appeals received.
• Update the Provider Dispute Database with resolution outcomes as appeals are completed.
• Keep the Team Supervisor informed of potential problem issues to educate all departments involved with claim issues.
• Advise management of issues impacting accurate claim processing or system configuration, particularly those affecting contracts or guidelines for non-contracted providers.
• Perform any other assigned duties as delegated by Management.