LaToya Bragg

• Understand Avesis’ contracts and performance requirements, claims processing workflow and payment process.
• Thorough knowledge of diagnostic and procedural coding for dental and/or vision claims.
• Skilled use of Avesis systems and applications for claims adjudication and research of provider, member, and utilization management data.
• Timely and accurate processing of claims as required in contractual and regulated time frames.
• Apply policies and procedures to confirm that claims meet the criteria for payment as indicated in contractual guidelines.
• Attendance in team meetings related to claims processing reviews and updates for company policies and procedures, audit findings, and other related communications.
• Ability to meet or exceed quality, accuracy, and production standards as determined by Avesis.
• Respond to inquiries from customer service team about claims in a 48hr time period.

● Complete complex credentialing forms accurately and compile requested documentation for packet

● Research government requirements and regulations for Medicare and Medicaid enrollment; prepare & submit required documentation for Medicare and Medicaid enrollment

● Research and complete full cycle execution of all necessary business licenses including, but not limited to: City, County, State, Bedding and HME/DME licenses and special requirements.

● Maintain and monitor records database with all credentialing and business

● Timely filing of all applications and renewals with commercial payers, Medicare and Medicaid agencies.

● Manage credentialing, licensing, and revalidation of Numotion locations and providers in assigned territory.

● Professionally Communicate with customers (internal and external) via, email and

● Organize and maintain detailed files in credentialing

● Adhere to the policies and procedures of Numotion

● Coordinate responses to all Medicare and Medicaid audits in assigned

● Complete all phases of pension and beneficiary processes including benefit calculations, notification of benefits, commencement of pension payments, and management of documentation.

● Assist customer base with plan related issues and requests including but not limited to COBRA, eligibility, claim escalation/resolution, life events, open enrollment, and retirement.

● Maintain SAP and other system data as required.

● Process invoices and exception reports from vendors; work with IT and Corporate HR to resolve issues; maintain a working relationship with vendor representatives.

● Maintain process documentation.

● Actively participate in projects, and suggest ideas for Continuous Improvement.

● Mentor peers regarding benefits knowledge and service standards.

● Participate in Peer to Peer Auditing, e.g., pension calculations.

• Research, investigate, and resolve escalated inquiries and issues related to code editing adjudication for all health plans.
• Triage all incoming inquiries and cases, answering escalated questions and issues from health plans and claim departments based on expertise of CMS, NCCI, CPT, and state coding guidelines
• Provide research necessary to address issues and concerns that potentially prevent provider abrasion and explain to providers why claims have been denied
• Train and audit team members on systems, coding principles, and state-specific guidelines using subject matter expertise of departmental protocols and state health plan guidelines.
• Maintain departmental policies and procedures for state health plans.
• Allocate and oversee daily workload for state health plans assigned, including code editing reviews, adjustments and appeals within code editing software systems (HCI and CXT)
• Prepare and analyze weekly & monthly departmental reports for state health plans to aid in identification of coding trends, cost savings, impact of adjustments/appeals to savings, and provider usage.
• Assist in identification of coding trends, cost savings, impact of adjustments/appeals to savings, and provider usage

● Accept or reject coding recommendations based on provider documentation, administrative policies, regulatory codes, legislative directives, precedent or other guidelines under the guidance of senior team members or management

● Compare provider billing and code auditing recommendations based on regulatory (Current Procedural Terminology) coding logic and state, CMS, and NCCI guidelines and rules

● Investigate and process appeals and adjustments for claims denied in code editing software systems (HCI or CXT)

● Maintain appropriate records, files, documentation, etc.

● Validate correct coding recommendations against state, CMS, and NCCI guidelines, resulting in cost savings to Centene for pre-payment, adjustments, and appeals.

● Researches claim service requests and performs adjustments as permitted

● Documents calls and forwards required information to the appropriate staff

● Responsible for accurate research and timely claims re-processing of all claim types, including coordination with the Corporate Claims Department

● Responsible of answering incoming calls from providers and members as they relate to eligibility, benefits, claims, and authorization of services

• Answer phones in a high volume call center for providers
• Assist with processing claims and quote benefits for providers
• Maintain metrics in order to service providers
• Research claims to ensure they processed correctly.
• Provide quality customer service to providers