Serviced FQHC’s and RHC’s for the State of South Carolina. • Acted as primary point of contact and liaison between the Health Plan and the Clinics, the billing team, the credentialing vendors and any other third-party vendors for the clinics. • Conduct monthly face to face meetings with providers, management teams and staff to discuss overall billing issues, action items, researching claims issues on site and analyzing next steps for resolutions. • Receive and effectively respond to provider related issues. • Research all claims related issues, identify claims and enrollment issues, and initiate research/resolve on all provider identified issues. Routing to the appropriate internal department for resolution. • Investigate resolved and communicated all provider claim issues and changes. • Provide education on health plans initiatives, educated providers regarding policies and procedures related to claims, claims submissions, web site usage, and other related items.

Performed detailed analysis on assigned projects, recommend potential business solutions and assist with implementation in the claims department. • Served as the liaison for claims payment between the plan, claims and various departments to effectively identify and resolve claims issues. • Performed audits of provider setup within the provider information system to ensure accurate contract implementation and subsequent claims processing.• Troubleshot and problem solved contract implementation issues related to basic system configuration. • Reviewed and priced contract related pends to ensure claims payment accuracy.• Audited check run and send claims to the claims department for corrections. • Reviewed contracts and assigned pay classes and applicable provider information based on contract language. If configuration is needed to accommodate a contract, notify the appropriate parties.

Served as the SME for the State of South Carolina FQHC, RHC and Dialysis Clinics. • Served as the liaison for claims payment between the plan, claims and various departments to effectively identify and resolve claims issues. • Analyze trends in claims processing issues, system changes, identify authorization issues, research potential configuration issues, track, and identify any provider billing/payment issues and claims inquiries. • Create, Track, Document, and Research claims on various reports to determine appropriate steps handling large scale provider issues as well as small individual provider issues on day-to-day bases. • Collaborate with the claims department by giving pricing, payment, pends, and claims instruction. • Directly working with the Regional Provider Network Relations representative to educate, direct on ATC guidelines, State guidelines, claims processing, payment policies and procedures as needed. • Audit check run and send claims to the claims department for corrections. • Collaborate work with various internal business units to resolve claims issues and ensure prompt and accurate claims adjudication.

Served as the SME for the State of South Carolina FQHC, RHC and Dialysis Clinics. • Served as the liaison for claims payment between the plan, claims and various departments to effectively identify and resolve claims issues. • Analyze trends in claims processing issues, system changes, identify authorization issues, research potential configuration issues, track, and identify any provider billing/payment issues and claims inquiries. • Create, Track, Document, and Research claims on various reports to determine appropriate steps handling large scale provider issues as well as small individual provider issues on day-to-day bases. • Collaborate with the claims department by giving pricing, payment, pends, and claims instruction. • Directly working with the Regional Provider Network Relations representative to educate, direct on ATC guidelines, State guidelines, claims processing, payment policies and procedures as needed. • Audit check run and send claims to the claims department for corrections. • Collaborate work with various internal business units to resolve claims issues and ensure prompt and accurate claims adjudication.

Served as the liaison for the State of South Carolina FQHC, RHC and Dialysis Clinics, acting as the SME in this role. • Serve as the direct contact for Appeals & Grievance department with regards to reprocessing overturned appeal claims. • Analyze trends in claims processing issues, system changes, identify authorization issues, research potential configuration issues, track, and identify any provider billing/payment issues and claims inquiries. • Directly working with the Regional Provider Network Relations representative to educate, direct on ATC guidelines, State guidelines, claims processing, payment policies and procedures as needed. • Conference call meetings with providers to discuss claims payment policies, procedures, and resolve claims issues. • Regularly run reports. • Review work process and pay class guides as it relates to resolving claims issues. • Handle large provider issues as well as small individual provider issues on day-to-day bases. • Collaborate work with various internal business units to resolve claims issues and ensure prompt and accurate claims adjudication.

Work directly as Team Lead- SME. • Work with appropriate departmental staff for projects, support activities, acting as the go to person for questions related to job functions. • Work directly with Management, Sr Management in transitioning of department.• Create Distribute & Monitor Monthly & Weekly reports to internal and external departments. • Manage workflow for team, distributing & monitoring. • Participate with conference calls and or meetings as requested.• Training new hire staff.

Initiate outreach with members to assess the need for Case Management.• Coordinates services for the members as needed.• Produce and mail routine CM letters and program educational material.• Perform task necessary to promote member compliance such as verifying appointments, obtaining lab results. Assess and monitor inpatient census. • Work with appropriate departmental staff for development projects and support activities. • Comply with prioritization process to reduce backlog of projects. • Maintain integrity of PHI. Attend ongoing training and in-services as directed. • Data enters assessments and authorizations into the system. Maintains database as directed.

Answer phone inquiries from both members and providers regarding claim, eligibility, covered benefits, authorizations status issues. • Educate member on procedures, benefits, payment and processing of Medicaid claims.• “Own” the issue through resolution with appropriate internal resources, such as Authorizations Pharmacy, and other Vendors associated with the Plan. • Document all calls for reporting and resolution through the phone log systems in MACESS.• Initiate or fax necessary forms to providers for member services.• Apply appropriate Medicaid rules and regulations when assisting providers with claims issues, ensuring claims are sent back for reprocessing, are adjudicated correctly, bringing closure to the issue.