Position Description: Health Insurance Specialist/ Subject Matter Expert

Under the direction of the Independent Dispute Resolution Entity (IDRE) Project Manager or his/her designee, the Health Insurance Specialist/ Subject Matter Expert applies critical thinking skills, IDRE program policies and reviews regulatory guidance to analyze and adjudicate eligibility, payment determination disputes between nonparticipating providers, nonparticipating emergency facilities or nonparticipating providers of air ambulance services or other services and a group health plan. The Health Insurance Specialist/Subject Matter Expert reviews all documentation received from the involved parties in regard to their proposed payment amount and renders an independent determination, selecting one of the two proposed offers, based upon the credible facts presented. In addition to review, the Health Insurance Specialist/Subject Matter Expert completes all case related documentation and sends appropriate email notification as per the established workflow. They are also responsible for timely and accurate case specific data entry into the government portal. Responsible for quality assurance of eligibility and payment determinations for the program.

Responsibilities:

• Understand and represent PRI's mission, vision, and values to all internal and external customers
• Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI management
• Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
• Proactively manages and coordinates activities to ensure timeliness of deliverables to exceed contractual obligations
• Interact with project team members in order to successfully fulfill contract obligations with the highest quality and in a timely manner meeting PRITM's ISO requirements
• Instills integrity throughout the organization via active participation in ISO requirements including but not limited to timely submission of Corrective Action Plans for all matters in which either PRITM standards and/or corporate contract standards have not been met. Communicating outcomes to team members to ensure a positive, open, environment which mitigates risk and achieves a culture of Continuous Quality Improvement.
• Contributes to business development efforts for new sales and marketing to promote the business through professional communications, sound decisions and by exceeding all contract timeframes and deliverable requirements,
• Utilize project resources for research and reference verification
• Demonstrated skill and experience in handling a large workload with varying deliverable dates
• Flexible with assignments to meet contract performance metrics
• Participate in interdisciplinary collaboration with PRI staff, recognized teaming partners, and/or subcontractors
• Demonstrated skill and experience in the submission of timely, accurate deliverables
• Demonstrated experience and skills in excellent customer service
• Proven skill and experience in excellent oral and written communication spanning executives to the general public
• Experience in analyzing, examining, adjudicating and resolving medical claims under the No Surprise Act or other similar federal law.
• Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI
• Perform duties of Health Insurance Specialist to ensure contract metrics are met
• Perform duties of Eligibility Insurance Specialist
• Performs independent dispute resolution review and payment adjudication activities as needed

• Perform other duties as requested

   

   

* Requirements:*

• Advanced degree in Health Care Administration, Health Care Insurance, or other related field preferred. May mee requirements with a bachelor's degree in a related field and an additional 4 years of directly related experience or an additional 8 years of experience in lieu of a degree
• Experience in analyzing, examining, adjudicating and resolving medical claims under the No Surprise Act or other similar federal law
• Ability to provide sound, defendable results in a quick and efficient manner.
• Superior Data Entry Skills
• Ability to thrive in a production based environment/Ability to multitask, work well under pressure and within timelines
• Strong analytical and problem solving skills with the ability to communicate solutions
• Excellent written and verbal communication skills
• Reliable and trustworthy; Integrity is required
• Excellent organizational skills and ability to pay attention to detail
• Ability to contribute to and work effectively within a team environment
• Ability to interface with management and contract staff personnel
• Proficient user of Microsoft office suite such as Outlook, Access, Excel and Word
• Ability to be discrete and maintain confidentiality
• Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
• Must have no conflict of interest (COI) as defined in 1154(b)(1) of the Social Security Act (SSA)Ability to obtain and maintain U.S. Government Security Clearance

Preference will be given to those individuals where their primary residency is located in a qualified HUBZone (http://map.sba.gov/hubzone/maps/)

FLSA Status: Exempt

The PRI Team Member Compensation Plan is applicable to this position.

PRI is an equal employment opportunity employer. All qualified applicants including Disability/Vets or other qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.

Qualified candidates may apply by clicking, "Apply Now". Next, submit your resume. You may complete a cover letter on the following screen. *You must contact the employer via one of the methods listed on the screen after clicking "Apply for this job". * Please be sure to identify PA CareerLink as your referral source.