What are the responsibilities and job description for the Provider Relations Specialist I/II position at AF Group Careers Section?
SUMMARY
Responsible for servicing internal and external customers who contact AF Group via the ACD phone line. Responsible for providing quality, consistent and accurate payment information to internal and external customers.
PRIMARY RESPONSIBILITIES include the following. Other duties may be assigned.
Provider Relations Specialist I:
- Utilizes ACD phone lines to manage incoming calls and inquiries.
- Provides high level of customer service for all internal or external customers thru telephonic, email and fax.
- Demonstrates a dependable work ethic.
- Manages confidential client information with discretion and good judgment in accordance with department and company guidelines.
- Identifies problems, provides solutions and resolves promptly, escalating more complex problems appropriately.
- Review state reporting criteria as related to bill processing and outlined in state guidelines.
- Refers to reference library of fee schedules, CPT, ICD-CM, HCPCS and other industry publications to support findings.
- Review, analyzes, adjusts and releases basic bills including duplicates.
- Responds to written or verbal provider inquiries relating to our bill review analysis.
- Analyzes problems using problem solving methodology skills to determine root cause; communicates and implements solutions.
- Types, photocopies, faxes as necessary.
- Create reconsiderations for processing.
Additional Responsibilities of Provider Relations Specialist:
- Responsible for performing technical review of more complex medical bills,
- Responsible for analyzing complex billings for multi-state Workers Compensation medical claims to determine appropriateness of services billed.
- Responsible for making bill review processing determination according to rules and regulations and/or third-party partner.
- Evaluates medical bills and corresponding EOR’s for accuracy and compliance with state mandate fee schedule(s) and our business rules and guidelines.
- Reviews inpatient hospital, outpatient hospital, and multiple surgery billings.
- Reviews, analyzes, adjusts and releases queued bills in an accurate and timely manner.
- Processes reconsiderations, as needed.
- Phone backup to Provider Relations Team as may be needed.
EDUCATION AND EXPERIENCE
Provider Relations Specialist I:
- High School Diploma or G.E.D is required.
- Minimum of three-year general office experience including answering inquiries over the phone required or equivalent relevant experience that would provide the required skills, knowledge, and abilities.
- Minimum of two years of experience in a medical billing and/or coding position required or similar relevant experience that would provide the necessary skills, knowledge and abilities to perform the required responsibilities.
Provider Relations Specialist II:
- High School Diploma or G.E.D is required.
- Degree/Certificate of completion in Medical Coding or Billing is required.
OR
Certification from AAPC, AHIMA or other nationally recognized organization as a medical coder or biller required.
- Minimum one year as a Provider Relations Specialist
OR
Minimum of 2 years demonstrated experience in workers’ compensation medical bill review analysis/pricing and a minimum of 3 years of relevant office experience which provides the necessary skills, knowledge and abilities.
QUALIFICATIONS
- To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
OTHER SKILLS AND ABILITIES
Provider Relations Specialist I:
- Basic knowledge of medical terminology, anatomy, CPT, ICD-CM codes and medical fee schedules.
- Excellent customer service skills.
- Excellent telephone etiquette.
- Ability to obtain pertinent and thorough information from customers
- Knowledge of computers and spreadsheet software.
- Ability to proofread documents for accuracy of spelling, grammar, punctuation, and format.
- Ability to perform mathematical calculations with the ability to use a ten-key pad with accuracy.
- Ability to manage work with minimal direction.
- Excellent oral and written communication.
- Demonstrate attention to detail.
- Ability to consistently meet or exceed daily production and quality standard for this position.
Additional Skills and Abilities of Provider Relations Specialist II:
- Working knowledge, experience, and ability to process bills using state medical payment methodologies.
- Ability to use independent discretion to make choices on proper reimbursement.
- Thorough knowledge of Worker’s Compensation multi state medical fee schedules, medical guidelines, medical terminology and CPT/ICD-9/10.
ADDITIONAL INFORMATION
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment.
REQUIRED TESTING (For HR use only)
Provider Relations Specialist I:
10 Key, Math, Reading Comprehension, Basic Excel
Provider Relations Specialist II:
10 Key, Math, Reading Comprehension, Basic Excel
