Claims Relationship Representative

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Claims Relationship Representative is responsible for accurate and timely response to claims inquiries received from providers and internal MetroPlusHealth departments. This individual will provide support to adjudication and adjustment of claims for the BPO Products at MetroPlusHealth. In addition, this individual will work closely with multiple internal departments including Provider Network Operations, Medical Management, Enrollment and Membership services and BPO Products.

• Act as a key liaison for claims and providers’ inquiries and problem resolution via telephone/correspondence.
• Respond to claim inquiries from providers including physicians, clinical staff, and site administrators.
• Coordinate and track appropriate problem resolution activities with plan personnel in other departments (i.e. Enrollment and Membership Services, DST BPO and Utilization Management)
• Manage and ensure appropriate follow-up and closure for all inquiries.
• Perform special projects and research as needed and participates in various work group projects.
• Ensure adherence to all Claims Processing Legislative and Regulatory requirements.
• Assist with Medicare claim inquires as needed and other duties as assigned.

• High School Diploma or General Education Equivalency Diploma required. Associate’s degree preferred.
• A minimum of one year of customer service experience and at least (3) years of claims insurance experience.
• Knowledge of Federal and State regulations and laws impacting the New York Health Benefit Exchange and the Patient Protection and Affordable Care Act a plus.
• Knowledge of Claims Processing/Adjustment protocols and payment
• Schemes including CMS claims processing guidelines.
• Knowledge of managed care, health care systems, and Medicare valuable and legal/regulatory requirements preferred.
• Strong ability to manage multiple assignments simultaneously.
• Basic competency in word processing, spreadsheets, database, and presentation software required
• Billing/coding experience is strongly preferred.
• Proficient in managing complex and at times emotional/furious calls from consumers

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Written/Oral Communication

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