Provides oversight of the claim adjudication processes provided by PCHP vendors.Establishes and monitors key performance metrics and trends to ensure compliance with all regulatory requirements and timely and accurate payments.Classify and troubleshoot claims and encounter issues.Provides team leadership, mentoring, and motivation.Communicates, collaborates, and cooperates with internal and external stakeholders respectfully and responsibly.Develops and maintains departmental policies and procedures.Stays up to date on Federal and State regulatory rules and mandates.Adheres to all Compliance/Program Integrity requirements and complies with HIPAA Regulations.

Manages the efforts of researching and resolving claims and claim encounter issues in a timely manner.Resolves issues related to claims and encounters through end-to-end review, Identifies the cause of the issue, and resolves through collaboration with all departments and individuals involved in the identified concern.Understands the impact of various departmental functions on claims adjudication and collaborates with other departments examples Provider Relations, Network Management and Member Relations to resolve issues impacting claim payments.Monitors claims and encounters key performance metrics and escalates issues when warranted.Identifies trends related to claim issues and advises leadership on interdepartmental process improvement opportunities to resolve provider abrasion.Provides information requested and resolves problems that arise involving claims.Partners with PCHP departments and vendors on the implementation of new programs and products.Communicates, collaborates, and cooperates with internal and external stakeholders in a respectful and responsible manner.Adheres to all compliance requirements and complies with HIPAA regulations.Perform extended duties and/or other special projects as assigned

Conduct analysis to identify root causes and assist with problem management related to requirements.Analyzes complex claims problems and issues using data from internal and external sources to provide insight to decision-makers from accounts. Identifies and interprets trends and patterns for internal operations-focused or external client-focused.Collaborates with clients to modify or tailor existing specific needs.Create an agenda’sHeld meetings with clients via WebEx phone Performed benefit analysis and identified fiscal impact for various procedure codes as they applied to projects. Overall assist subject matter expert in Medicaid.Reviews, researches, analyzes, and evaluates all data relating to specific areas of expertise.Assist on test plan documentation to support system validations.Ability to articulate an appropriate course of action based on reading standard projects.Meeting deliverable to ensure compliance with health plan/state standards on provider data.Assisted the Medicaid managers and Directors in compliance issues for completion.

Analyzed specific Provider Inquiries related to Disputes and Appeals.Maintains tracking system of correspondence and outcomes; maintains well-organized, accurate and complete files for all appeals.Monitors each appeal to ensure all internal and regulatory timelines are met.Responsible for data collection and analysis regarding provider inquiries and/or disputes.Research and documents denial determinations at all levels of provider appealsActs as point of contact for submission and/or resolution of denial determinations and practitioner appeals. Interfaces with Provider Services regarding provider disputes and/or appeals.Key contributor in developing and updating policies and procedures related to Provider Disputes and Member AppealsCoordinates workflow between departments and interfaces with internal and external resources.Prepares or assists in the preparation of the narratives, utilized for committee presentations and audits.Composes all correspondence and appeal information concisely and accurately, in accordance with regulatory requirements.Assists in developing policies, procedures, and quality assurance measures related to provider inquiries/disputes.Participates in the provider hearing process as well as alleviates unnecessary hearings through research.

Experience in a Medicaid production environment.Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.Abilities to do claim reporting - distribute assignments to the team daily balance the production number by the ending week.Problem solving and analytical skills - Identifying claims over-payment, underpayment, and other irregularities.Reviews documentation regarding updates/changes to member enrollment, provider contract and provider demographic informationConducts focal audits on samples of processed claims impacted by these provider and contract updates/changes.Determines that claim editing, provider information and contract terms are aligned to the original documentation and allow appropriate processing.Knowledge of benefit plans, policies, and procedures.Performed routine review of claims samples to ensure appropriate payment in accordance with Texas Medicaid Policy.Identified claims over-payment, underpayment, and other irregularities.Communicate/assist with insurance carriers and addressing claims and coverage issues facilitating resolutions.Handled outbound calls to obtain required information for first claim submissions or reconsideration.Claims processing and adjustments.