Claims, Audit and Recovery
Provider Claims Service Representative
Louisville , KY, United States

It’s Time For A Change… Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely--62% in year-over-year revenue growth through 2015. Are we recognized? Definitely. We’re 12th on Forbes’ list of America’s Most Promising Companies for 2015, one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

What You’ll Be Doing:

This position is responsible for immediate responses to incoming provider calls regarding claims issues in a call center environment, as well as reprocessing claims as identified through incoming phone calls or submitted by provider relation’s staff.

Principal Accountabilities:

  • Investigates and responds in a timely manner to incoming provider calls and correspondence maintaining excellent relationships with the provider community. 
  • Identifies systematic and procedural issues resulting in claims processing errors and initiating action to resolve those issues. Documents calls, problems, and resolutions for future reference. 
  • Meets standards for taking incoming provider calls maintaining department standards for average speed of answer, call abandonment.
  • Maintains knowledge of provider contracts, plan policies and coverages, claims processing guidelines and systems, and an overall understanding of operational workflows and processes.
  • Identifies, reverses, and processes adjustments to claims processed in error.
  • Documents all findings and actions taken as a result of provider inquiry.
  • Communicates to providers plan policies, coverage, and procedures.
  • Interacts with other departments to obtain prompt and accurate resolutions to issues.
  • Assists in providing quality improvement feedback regarding systems, procedures, policies and performance. Communicated to claims processing management findings of errors and provides appropriate documentation.
  • Assists with departmental projects when needed and contributes to completion of projects by a given deadline.
  • Maintains strict confidentiality of patient information, financial information, and volume/workflow information.
  • Demonstrates a high degree of ownership and accountability for the resolution of provider concerns.
  • Document workflow into EXP program.
  • Process claims using FACETS and IKA systems.
  • Review JIVA system for provider authorizations.
  • Utilize State system to determine Coordination of Benefits (COB) information for members. 
  • Utilize IHealth Inquiry system.
  • Review website to monitor updates to National Correct Coding Initiative (NCCI) standards.
  • Perform other duties and projects as assigned.
    Key Competencies/Success Factors:
  • Lives the values: Integrity, Community, Collaboration and Stewardship, as defined in the performance appraisal.
  • Strong customer service and interpersonal skills. 
  • Excellent verbal and written communication skills. 
  • Proficient experience using Outlook, Word, Excel and PowerPoint in a Windows operating system. 
  • Must be detail oriented.
  • Ability to adapt to fluctuating situations and perform work of a detailed nature, avoiding errors.
  • Ability to multi-task calls and correspondence on a daily basis.
  • Proficient skills in maneuvering through multiple systems on a daily basis.
  • This position primarily works in a climate controlled based setting. The noise level and the work environment are moderately quiet. 

Finishing Touches (Preferred):

  • Bachelor’s degree preferred.
  • 1 year managed care or related experience preferred.
  • Healthcare customer service experience preferred.
  • Customer service experience preferred.
  • 3-5 years of experience as a Provider Claims Service Representative or comparable experience preferred.
  • Medical claims coding certification preferred.

Evolent Health is an Equal Opportunity/Affirmative Action Employer


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