Melissa Paul Email & Phone Number

Margate

Plantation , Fl

We Handle customer questions and resolves issues via telephone, internet, or written correspondence from members, providers, and plan sponsors.Triage resulting rework to appropriate staff. Documents and tracks contacts with members, providers and plan sponsors.Explains member's rights and responsibilities in accordance with contract.Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target… Show more We Handle customer questions and resolves issues via telephone, internet, or written correspondence from members, providers, and plan sponsors.Triage resulting rework to appropriate staff. Documents and tracks contacts with members, providers and plan sponsors.Explains member's rights and responsibilities in accordance with contract.Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system.Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues.Responds to requests regarding litigation; lawsuits.Handles extensive file review requests. Assists in preparation of complaint trend reports.Assists in compiling claim data for customer audits.Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals.Handles incoming requests for appeals and pre-authorizationsPerforms review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary.Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received. Show less

Coral Springs, Fl

Coral Springs