Provider Relations Specialist

Job Description

Provider Relations Specialist I and II are tasked with servicing internal and external customers who contact AF Group via the ACD phone line and providing accurate medical payment information.

• Utilises ACD phone lines to manage incoming calls and inquiries.
• Provides high‑level customer service for all internal and external customers via telephone, email and fax.
• Demonstrates dependable work ethic.
• Manages confidential client information with discretion and good judgement in accordance with department and company guidelines.
• Identifies problems, provides solutions and resolves them promptly, escalating more complex issues appropriately.
• Responds to written or verbal provider inquiries regarding bill‑review analysis.
• Analyzes problems using problem‑solving methodology to determine root cause; communicates and implements solutions.
• Types, photocopies and faxes as necessary.
• Creates reconsiderations for processing.

• Performs technical review of complex medical bills (e.g., modifiers, anesthesia, psychiatric).
• Analyzes complex billings for multi‑state workers’ compensation medical claims to determine appropriateness of services billed.
• Issues bill‑review processing determinations according to rules, regulations and/or third‑party partners.
• Evaluates medical bills and EORs for accuracy and compliance with state‑mandated fee schedules and company business rules.
• Reviews inpatient, outpatient and multi‑surgery billings.
• Reviews, analyzes, adjusts and releases queued bills in an accurate and timely manner.
• Refers to reference library of fee schedules, CPT, ICD‑CM, HCPCS and other industry publications to support findings.
• Processes reconsiderations as needed.
• Provides phone backup to the Provider Relations team as required.

Education

• For Specialists I:
  High School Diploma or G.E.D. required; completed coursework or enrollment in Medical Insurance Billing and Coding beneficial.
• For Specialists II:
  Certificate in Medical Billing required.

Experience

• Specialists I:
  Minimum of three years general office experience, including answering inquiries over the phone or equivalent.
• Specialists II:
  Two years as a Specialist I or three years’ experience in an insurance organization with two years of technical knowledge in workers’ compensation medical bill review.

Skills, Knowledge & Abilities (SKA) Required

• Excellent customer service and telephone etiquette.
• Knowledge of a multi‑functional phone system.
• Ability to obtain pertinent information from customers.
• Computer and spreadsheet proficiency.
• Typing speed of 40 wpm.
• Proofreading skills.
• Mathematical calculation and ten‑key proficiency.
• Multi‑tasking ability.
• Independent work management.
• Verbal and written communication skills.
• Attention to detail.
• Consistent achievement of production and quality standards.

Additional Skills for Specialists II

• Working knowledge of state medical payment methodologies.
• Independent discretion to determine proper reimbursement.
• Knowledge of workers’ compensation multi‑state fee schedules, medical guidelines, terminology, CPT and ICD‑CM.
• Basic understanding of Workers Compensation Act.
• Preferred background in workers’ compensation.
• Degree or certification in medical coding.
• Experience on an ACD telephone system.

Work is performed in an office setting with no unusual hazards.