Perform various analyses and interpretations to link business needs and objectives for assigned functions.Support business initiatives through data analysis, identification of implementation barriers, and user acceptance testing of new systems.Identify and analyze user requirements, procedures, and problems to improve existing processes.Perform detailed analysis on assigned projects, recommend potential business solutions, and assist with implementation.

Supports department goals by maintaining all network provider data received from business units. Conducts audits and analysis in accordance with provider contracts, claims, and regulatory requirements while using experience with data extracts, manipulation and/or data management. Designs, coordinates, and produces reporting required for internal and external stakeholders and regulatory agencies. Provides recommendations on process or system improvements, communicates with key stakeholders with regard to research requests and general inquiries.

Serve as a liaison between the plan, claims, providers and various departments to effectively identify and resolve claims issues• Audit check run and send claims to the claims department for corrections• Identify any system changes and work notify the Plan CIA Manager to ensure its implementation• Collaborate with the claims department to price pended claims correctly• Document, track and resolve all plan providers’ claims projects• Collaborate with various business units to resolve claims issues to ensure prompt and accurate claims adjudication• Identify authorization issues and trends and research for potential configuration related work process changes• Analyze trends in claims processing issues and assist in identifying and quantifying issues and reviewing work processes • Identify potential and documented eligibility issues and notify applicable departments to resolve• Research the claims on various reports to determine if appropriate to move forward with recovery due to non-covered items being allowed, etc.• Run claims reports regularly through provider information systems• Research verbal and written providers’ claims inquiries as needed

• Daily processing of referral and authorization service requests within TRICARE contract time standards• Makes benefit and coverage determinations based on TRICARE policy and UHCMV guidelines • Processes MTF requests for identification and steerage for in network physician specialty referrals• Sets up/documents/triages cases for Clinical Prior Authorization Review• Verifies appropriate ICD-9,10 and CPT/HCPCS codes• Resolve customer service inquiries which could include: Enter referral/notifications, change provider status of an existing referral/notification and determining if referral/notification is required• Assist with faxes, emails, and letters to the beneficiaries, civilian providers and the MTFs• Make outbound calls as needed to providers to gather required information for referrals and authorizations

Essential Duties And Responsibilities Develops and maintains positive working relations with the transportation providers and LogistiCare staff Updates Director of Operations on outcome of his/her communications with the transportation providers Accepts complaints from transportation providers or LogistiCare staff and maintains complaint resolution database on daily basis; shares database with Director of Operations and General Manager.• Communicates with transportation providers when applicable• Meets all departmental deadlines• Identifies any problems with transportation billing• Maintains/updates call logs• Maintains/updates Excel spreadsheets• Attends all required meetings• Maintains an acceptable attendance and tardiness record• Adheres to company policies and procedures• Meets with management to discuss training/ workflow issues• Performs other administrative duties as assigned

Essential Duties & Responsibilities• Inputting provider charges and interest into database for all Broker Clients• Track all missing claims for check run until resolved. Check run cannot have any missing claims • Ensuring Data fields in Delta Force are complete and accurate• forwarding dual denial claims to client for resolution• Assisting operations staff in researching provider claim inquires• Preparation of provider pending & take-back actions - weekly• Run and coordinate Open Claims Report(s)• Reconcile checks from corporate and mailing of checks• Special projects as assigned• Answer and provide support for EOP processes, to all incoming phone calls received on the 800# assigned to the Provider Help Desk• Tracer claim resolution• Resolving provider refunds• Check run production (Printing EOPs and balancing payment amounts)• Other duties as assigned

EssentialFunctions:• Operates water equipment to perform specific operations as assigned professionally & efficiently.• Operates assigned equipment according to applicable policies and procedures: assures safety standards are maintained.• Takes actions to avoid potential hazards and obstructions such as utility lines, other equipment, other workers, and falling objects.• Completes daily walk-around inspections of equipment to insure unit is in good operating condition and reports problems found to Supervisor and or Shop.• Maintains the cleanliness of assigned equipment.• Keeps records of material and equipment usage and problems encountered.• Completes general labor assignments, and assists other field personnel as required.• Assists with repair and or maintenance of equipment as needed.• Works with and monitors fellow workers to insure safety and productivity.• Performs other duties as assigned

Non Commissioned Officer , Squad Leader for a weapons platoon. 60mm Mortars