Maria Jackson

Position Purpose: Processes and maintains eligibility information for routine individual and/or employer groups under general supervision.

• Maintains accurate eligibility records for individuals and/or assigned employer groups. Process all enrollments; plan changes, and disenrollment transactions
• Reviews aging to determine delinquent accounts, membership reconciliation issues from premium issues. Produces and distributes delinquent notices to members.
• Provides daily support on incoming verbal or written correspondence enrollees regarding eligibility and processing status
• Communicates policies, procedures and benefits to employees, enrolled members or, if applicable, employers. Interacts with staff in other departments to clarify and resolve eligibility problems presented by members.
• Provides cross training and back-up assistance to other enrollment groups.
• Provides support within service operations as needed such as Membership Accounting.

• The Inbound Contacts Representative II addresses customer needs which may include complex benefit questions, resolving issues, and educating members.
• Records details of inquiries, comments or complaints, transactions or interactions and takes action in accordance to it.
• Escalates unresolved and pending customer grievances. Decisions are typically focus on interpretation of area/department policy and methods for completing assignments.
• Works within defined parameters to identify work expectations and quality standards, but has some latitude over prioritization/timing, and works under minimal direction.
• Follows standard policies/practices that allow for some opportunity for interpretation/deviation and/or independent discretion.
  

• Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review).
• Provides information regarding network providers or general program information when requested.
• May assist with complex cases.
• May act as liaison between Medical Management and/or Operations and internal departments.
• Maintains and updates tracking databases.
• Prepares reports and documents all actions.
• Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.

• Provided appropriate issue resolution and/or escalation when needed. Works as a supervisor in training.
• Participates in special projects and performs other duties as assigned.
• Act as First point of contact for escalated calls and requests.
• Responsible for the Assignment of work to Associates
• Manages payer, provider and patient complaint resolution.
• Works with supervisors and staff employees to drive efficient call volume activity and management.
• Work with supervisors to create efficient work plans and daily assignments.
• Respond to calls/e-mails in a timely manner.
• Proficient with entering information into CART (complaint) system.
• Ensures the coordination of invoice activities leading to timely reimbursement of receivables using available resources including databases, internet, and telephone.
• Researches and resolves denials received that have not passed payer edits and may lead to a final appeal of denied services. Requires knowledge of a variety of system applications both internal and external. Determines and initiates action to resolve rejected invoices, prepares payer corrections, and/or appeals using electronic and paper processes.
• Oversees accounts receivable adjustments to resolve overpayments and payment rejections according to standard operating procedures. Analyzes and clears payment variances. May prepare adjusted and corrected bills or adjust accounts receivable entries in accordance with existing operating procedures. May include the use of special reporting.
• Contacts providers, physicians, and/or patients to retrieve appropriate medical documentation to substantiate services provided and engage them in assisting CareCentrix in collecting for the payer.
• Provide payers with detailed itemization of services performed to ensure timely reimbursement. Review EOPs/EOMBs/EOBs for accuracy of patient responsibility.

• Managed multiple tasks, detail oriented, responsive, and demonstrated independent thought and critical
  thinking.
• Contacted provider's to staff home health services as well as staffing medical equipment services.
• Worked closely with health plans/payers and maintains strong business relationships.
• Provided appropriate issue resolution and/or escalation when needed.
• When working outside of the CareCentrix network adheres to out-of-network qualification standards and ensures pricing is commensurate to CareCentrix client reimbursement.
• Worked under moderate supervision, with clinical oversight.
• Participated in special projects and performs other duties as assigned.

• Receives and responds to incoming calls from providers, referral sources, and potential patients.
• Accurately enters information to begin the referral process into the CareCentrix portal and accurately records the outcome of calls in the proper screen.
• Collects and enters clinical and demographic information to begin the referral process along with verifying eligibility and benefits information by contacting health plans or payers to ensure services provided will be covered by the carrier. (e.g., deductible amounts, co-payments, effective date, pre-existing causes, levels of care, authorization, visit limitations, documentation required to process claims, etc.).
• Accurately documents all communications and decisions into a computer database.
• Consults applicable Payer Fact Sheets in Intake Process. Works with other staff and patients to identify.
  potential solutions as problems are identified with payer sources.
• Identifies potential payer sources, obtains authorization from the authorizing entity. Accurately documents conversations and decisions with payer sources.
• Files CARTs (complaints), completes the Internal Issue Log, and Start Of Care templates when applicable.
• Works closely with health plans/payers and maintains strong business relationships.
• Provides appropriate issue resolution and/or escalation when needed. Works under moderate supervision, with clinical oversight.

• Review new applications and supporting documents in a virtual environment and apply policy and criteria
  required for credentialing processing.
• Maintain and update credentialing database records.
• Review malpractice history, regulatory and disciplinary action reports issued by state and federal agencies
  invoking appropriate processes as defined in policies and procedures.
• Review the CAQH (Council for Affordable Quality Healthcare) system and download applications or
  supplemental documents as appropriate.
• Maintain electronic provider files.
• Perform outreach to providers and facilities via phone calls and fax/email correspondence.
• Demonstrate knowledge of credentialing regulatory and accreditation requirements (CMS (Content
  Management System), Medicaid etc.).

• Provides claim follow ups, resolution of and payment from insurance companies for unpaid claims of physicians. 
• Completing outstanding insurance reports, researching insurance correspondence, documenting in the Medic computer system, following up on customer inquiries and/or complaints, and communicating with other departments. 
• Posting of insurance and patient receipts, customer service phone calls, and assisting departments to resolve accounts.