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Providence Health & Services Technical Operations Financial Transactions Specialist in Beaverton, Oregon

Description:

Providence St. Joseph Health is calling a Technical Operations Financial Transactions Specialist to our location in Beaverton, OR.

We are seeking a Technical Operations Financial Transactions Specialist who will be responsible for improving the quality of service provided to Health Plan members and practitioners on the Operations Financial Transactions Team through quality analysis, training and other activities. Total quality will be achieved by an integrated approach to quality assessment, quality improvement activities, and staff training supported by documentation. The work will focus on defining and assessing individual and health plan performance against established indicators, developing and revising training and documentation to improve identified performance gaps, and identifying and leading quality improvement projects to streamline and improve health plan business processes. This integrated holistic approach will result in higher customer, practitioner and employee satisfaction due to service and productivity gains.

In this position you will have the following responsibilities:

COB:

  • Review Facets work queue to identify claims without COB information on file. Research other coverage and set file up in accordance with state and federal regulations as well as employer agreements.

  • Enter other coverage information via enrollment process (paper enrollment forms, Web enrollment, electronic enrollment or in-house reporting). Ensure information is accurate by contacting the other carrier or member for verification of information. If necessary, obtaining copies of court orders or plan documents. This may also include a special member mailing if needed.

  • Review Customer Service Inquiries (CSI) and respond promptly to questions or complicated member set up.

  • Completes Medicare Secondary Payer annual mailing to determine if PHP is the primary carrier over Medicare.

  • Works daily and monthly reporting from CMS regarding potential changes in Medicare eligibility.

  • Responds to/or initiate telephone inquiries from/to members, other health plans, or providers within the next business day.

  • Handles correspondence resulting from any part of the COB set up process.

  • Follow up on all leads from refunds received, phone calls, or any other source which indicates a possibility of other coverage.

  • Initiate modification of policy and procedure documentation to improve results or reflect required changes in the area of COB.

  • Develop online documentation for Service Specialists based on information received from a variety of sources.

  • Training appropriate staff on new policies and procedures dealing with COB in both formal and informal setting.

  • Requests refunds on overpayments identified in a timely manner.

  • Member file clean up, including reprocessing of claims based on information received regarding other insurance coverage.

  • Provide education to members/providers on appropriate COB guidelines.

  • Be a strong advocate in adhering to BRITE behavior and by modeling it on a consistent daily basis.

OPR:

  • Utilize decision making skills to determine if a refund is appropriate and which claim (s) it applied to, or if it applicable to write off a refund requested refund of less than $10.00 (PHP policy).

  • Initiate refund requests to providers, and members and determines liability of the plan.

  • Monitor refund requests and follow up on outstanding requests after the initial 60 days.

  • Monitor refunds database, provider aging report and other reports to ensure claims are adjusted appropriately and the claim has been receipted within 30 days from the receipt of the refund check or wire.

  • Handles correspondence resulting from any part of the refund process.

  • Follow-up on all leads for overpayments. Work reports; analyze data to ensure accurate refunds are requested.

  • Post HCRI and Phia recoveries.

  • AIM recoveries, approve refunds and post recoveries.

  • Work with providers in conjunction with Provider Relations on contested or disputed refunds.

  • Review and transmit AP checks to Regional Accounting.

  • Perform write-offs for under $100 as uncollectable as appropriate.

  • Facilitates sending outstanding refunds to our external collections agency.

  • Initiate modification of policy and procedure documentation to improve results or reflect required changes in the area of OPR.

  • Training appropriate staff on new policies and procedures dealing with OPR in both formal and informal setting.

  • Take calls from Service Operations, Provider Billing Offices and member regarding overpayments and refunds requested.

  • Apply refunds to the appropriate database (Facets or non-Facets queue) and readjudicate claims as appropriate.

  • Develop online documentation for Service Specialists based on information received from a variety of sources.

  • Request AP checks as appropriate to return funds to members, providers or employer groups.

  • Review and apply auto recovery requests received via the RBO in-box.

  • Determine appropriate claims and line of business to credit in order to properly post refunds.

  • Determine appropriateness of writing off refunds requested of less than $10.00 (PHP policy).

  • Be a strong advocate in adhering to BRITE behavior and by modeling it on a consistent daily basis.

TPL:

  • Utilize essential decision making skills to determine if a claim can be released of if further investigation needs to be made.

  • Initiate accident inquiry to member (and review accident letter as completed by member) and determine liability of PHP.

  • Obtain case information for identified cases and prepare set up for the Subrogation Analyst.

  • Monitor aging reports and CSI’s to ensure that pended claims are resolved within timeliness guidelines.

  • Ensures claims are adjudicated appropriately adhering to established TPL policies and procedures.

  • Review customer service inquiries, follow up and respond as appropriate.

  • Monitor subpoenas and records requests for timeliness.

  • Communicate with outside members and attorneys while TPL cases are still open and settlement has not been reached. Ensuring all necessary documents have been received.

  • Follow up on open cases to determine if settlement has occurred.

  • Provides medical liens to attorneys to assist in negotiating settlement and facilitating reimbursement to PHP.

  • Utilize assistance from RCGA or internal legal staff when appropriate.

  • Requesting of refunds related to paid claims where third party liability has been determined.

  • Handles correspondence resulting from any part of the investigation process.

  • Follow-up on all leads from refunds received, phone calls, etc. which indicates a possibility of a third party liability.

  • Acknowledge telephone inquiries from members, attorneys, insurance adjusters and providers within the next business day.

  • Training appropriate staff on new policies and procedures dealing with TPL in both formal and informal setting.

  • Develop online documentation for Service Specialists based on information received from a variety of sources.

  • Initiate modification of policy and procedure documentation to improve results or reflect required changes in the area of TPL.

  • Be a strong advocate in adhering to BRITE behavior and by modeling it on a consistent daily basis.

Qualifications:

Required qualifications for this position include:

  • High School Diploma or GED.

  • 2 years experience in a business environment.

  • 1 year experience in an analyst role, fully trained in at least one functional area (third party liability, coordination of benefits, over-payment recovery), and an in-depth knowledge of all Operations Financial Transactions responsibilities.

  • 1 year experience with health plan computer software such as Facets and Imaging.

Preferred qualifications for this position include:

  • Bachelor's Degree or 5 years experience in a related field.

  • 2 years experience in a business environment, preferably in health insurance.

About Providence in Oregon.

As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.

The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple, "Providence will provide the best care and service to every person, every time."

Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.

For information on our comprehensive range of benefits, visit:

http://www.providenceiscalling.jobs/rewards-benefits/

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: Full-time

Shift: Day

Job Category: Finance

Location: Oregon-Beaverton

Req ID: 290053

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