Completes healthcare physician enrollment applications with insurance payorsCreate and maintain insurance and provider credentialing files according to HIPAA regulations and insurance credentialing spreadsheets for reporting purposesKeep up to date on market trends in insurance credentialing and changing regulations and verify with insurance payers that providers are appropriately established to bill for professional services in the claims processing systemHandle related physician re-credentialing matters as due dates arrive

Provides internal support to Network team by researching and resolving provider issuesPrepares documentation for meetings, schedules meetings, visits PCP/specialist officers for relationship building, and educate providers regarding member benefits and referral processDevelop, maintain, and distribute reports. Perform quality checks on provider communication material. Maintain provider contract files and system informationAssist with physician bonus distributionResponsible for support of the Ancillary Network team through problem resolution and researching appeals for hospital and ancillaries through claims review, pricing, and authorization requirementsResearch MSM inquiries through the claims systems to resolve discrepancies and draft letters to send to providers for resolution to issues

Process Member Maintenance for group policies. Enrollment and Terminations of expatriate membersMake member and dependent eligibility updates, salary and/or address changes, generate ID cards and assemble and distribute member kitsConduct membership audits Assist Account Managers with client/member customer service. Assist members through enrollment process

Direct contact person for Commercial Insurance Contract NegotiationsManaged contracts and rate reimbursements for skilled nursing care, acute and sub-acute care for nine Assisted Living and Long Term Care facilitiesMaintained employee database tracking new hires, applicants and terminationsConducted quarterly audits at each facility of employee personnel and health files

Participated in the process of ancillary and specialty provider contracting, including preparing contracting packages, preparing all documents for contract implementation, managing applications and credentialing documentation for network providers and physiciansResolved billing reimbursement and claims issues for Providers. Conducted routine negotiations with non-participating providers for authorized services, on a case by case basisWorked in conjunction with the Manager and Director to ensure oversight and compliance of all specialty programsEducated primary ancillary and specialty providers on Heath Partners' policies and procedures by conducting new orientation training and in-serviceServiced providers by promptly responding to calls, inquiries and complaints and assist in resolving providers' issues

Developed, implemented and oversaw effective quality control processes for the enrollment of new and existing businessGenerated billing reconciliations of employer group membership to verify CMS enrollmentCoordinated the development, revisions and printing of marketing brochures, rate sheets for brokers, associations and direct sales executives and responded to these requests Supported the Group Manager and ensured special projects and deadlines were metConducted internal training sessions on an individual or group level based on quality control findings or changes to enrollment, service procedures or underwriting and participation requirementsServed as a liaison between Medicare Sales and Commercial Sales, Medicare Eligibility Verification and Medicare EnrollmentReviewed and monitored Medicare Secondary Payor regulations to assure compliance and acted as a resource to employer groups, commercial marketing and internal Medicare Sales and staff

Responsible for the timely and accurate preparation of large Group Contracts and for language changes to the documents used for processing contractsTelephone and email contact with outside and inside vendors and Marketing Representatives

Responsible for the timely and accurate preparation of Enrollment Benefit Memorandums and ContractsUtilized WordPerfect & EBM Viewer & Editor to prepare EBM documents that are locked onto the mainframeAssisted in the training of co-workers in the processing of EBMs.

Provided Administrative Support to all Marketing RepresentativesKeyed original and audited group histories and cancellations onto the Marketing Tracking SystemResponsible for the timely and accurate delivery of the group histories to the processing departmentLogged, copied, sorted and distributed Line of Business Credibility Change Forms and RenewalsUpdated all new information for Groups that was necessary for the Keyperson Address FileAssisted in Answering telephone lines on the Keystone Marketing Hotline

Provided telephone customer service to individuals by answering questions pertaining to enrollment, billing, identification cards, refunds and transfers to other Blue Cross plansResponded to Correspondence sent in by subscribers; Processed enrollment applications. Sent out benefit verification letters

Reported data and analyzed information statistics of all Group Enrollment Memorandums and Group Cancellations for all areasControlled the steady flow of dates on NMIS system and subscriber counts for each groupResponsible for assigning work to processing areas and keeping track of all dates on group historiesProof reed all EBMs that were generated and made any necessary corrections so that they could be uploaded to the GEBM file