Provider Relations Specialist

Compensation:
Competitive Compensation and Benefits Package

AF Group’s focused and passionate team uses industry-leading best practices, analytics and resources to manage risk and minimize loss for our policyholders while strengthening businesses with our valued independent agent partners.

We strive to continuously increase the long-term value of our organization by outperforming our industry peers and fostering a culture of underwriting and claims excellence.

(This position will be Hybrid (1-4 work from home days) after the training is completed)

Provider Relations Specialist I:Responsible for servicing internal and external customers who contact AF Group via the ACD phone line. Responsible for providing quality, consistent and accurate medical payment information to internal and external customers.

Provider Relations Specialist II:Responsible for analyzing billings including outpatient hospital and multiple surgeries by utilizing our Medical Bill Review (M ) software and reference library to determine appropriateness of codes and excessive charges. Responsible for making coding determinations according to state rules and regulations.

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

Provider Relations Specialist I:

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

Provider Relations Specialist II:

• Responsible for performing technical review of more complex medical bills, including but not limited to modifiers, anesthesia, & psychiatric.
• Responsible for analyzing complex billings for multi-state Workers' Compensation medical claims to determine appropriateness of services billed.
• Responsible for making bill review processing determination according to rules and regulations and/or third-party partner.
• Evaluates medical bills and corresponding EOR’s for accuracy and compliance with state mandate fee schedule(s) and our business rules and guidelines.
• Reviews inpatient hospital, outpatient hospital, and multiple 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 publication to support findings.
• Processes reconsiderations, as needed.
• Phone backup to Provider Relations Team as may be needed.

EDUCATION REQUIRED:

• Provider Relations Specialists I:
  High School Diploma or G.E.D. required.
• Completed coursework or enrolled in Medical Insurance Billing and Coding.
• Provider Relations Specialists II:
  Certificate in Medical Billing, required.

EXPERIENCE

REQUIRED:

• Provider Relations Specialists I:
  Minimum of three-year general office experience including answering inquiries over the phone or equivalent relevant experience that would provide the required skills, knowledge, and abilities.
• Provider Relations Specialists II:
  Two years as a Provider Relations Specialist I.
• OR Three years’ experience in an insurance organization with two years demonstrated technical knowledge in workers’ compensation medical bill review or other relevant…