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City/State
Doral, FLOverview
Work Shift
First (Days) (United States of America)AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Provider Contestment Reviewer in Miami and/or Gainesville, Florida. This is a hybrid position, 2 days in office and 3 days remote.
Scope of position:The Provider Contestment Reviewer is responsible for processing claims that have been paid in excess of AvMed's contractual obligation. Make adjustments and/or send correspondence when necessary.
Essential Job Functions:
- Monitor aging of provider overpayments/receivables. Develop and execute strategies to recoup the funds from the providers. Work with Network and external agencies to recoup uncontested aged receivables.
- Ability to review, process, register and post in HRP all types of checks (solicited and unsolicited).
- Review and process contested overpayment letters/claims.
- Interpret and apply AvMed's policies and claims administration procedures.
- Ability to work and report results of overpayment projects.
- Meet the department's production and quality standards. Focus on achieving departmental and organizational objectives.
- Identify and report system and configuration issues.
- Complies with company policies and procedures, which includes dress code, punctuality as they relate to work time, lunch, and break periods.
- Must have the ability to effectively communicate both verbally and in writing with providers for the purpose of adjustment, as well with members regarding retroactive terminations.
- Performs additional duties and responsibilities as assigned by management.
Minimum Requirements:
- High School diploma required
- Associate in business or any related field preferred
- 3-5 years of experience in a complex managed care environment with multiple products and entities, with an emphasis in claims, pricing and/or benefits within healthcare. Previous audit or system configuration experience preferred
- An equivalent combination of education and experience may be considered
Preferred Requirements:
- Strong verbal and written communication skills
- Strong analytical and interpretative skills
- Excellent organizational skills
- Effective problem-solving skills and ability to handle simple and complex tasks.
- Detail-oriented skills to adapt to various workflows, multiple tasks, deadlines and changing priorities
- Medical Coding including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-10) and Diagnosis-related Group (DRG) Codes
- HRP, MACESS, or Similar Software Systems
- Microsoft Office Suite (Word, Excel, Access)
Our Benefits:
As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to:
- Medical, Dental, and Vision Insurance
- Paid Annual Leave, Sick Leave
- Flexible Spending Accounts
- Retirement funds with matching contribution
- Supplemental insurance policies, including legal, Life Insurance and AD&D among others
- Work Perks program including discounted movie and theme park tickets among other great deals
- Opportunities for further advancement within our organization
Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Benefits - Sentara (sentaracareers.com)
Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, and growth!
Note: Sentara Healthcare offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.
Keywords: Talroo-Health Plan, #INDEED, Claims, Pricing and or Benefits
Job Summary
The primary role of the Provider Data Enrollment Specialist I is to ensure the data integrity of provider records entered and maintained in the credentialing and/or payment systems. This position may be responsible for all aspects of ensuring accurate and timely processing of provider setup to initiate credentialing, provider record updates and edits, processing provider terminations, and researching and resolving provider setup issues in the applicable systems. This data maintenance will support network adequacy and growth, regulatory reporting, provider directories, as well as downstream systems and processes.Minimum of 1-year experience in healthcare insurance working with provider, network, or contract data; or a combination of education and experience, which would provide an equivalent background
Understanding health claims processing is a plus
Qualifications:
HS - High School Grad or Equivalent (Required)InsuranceSkills
Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.
In support of our mission "to improve health every day," this is a tobacco-free environment.