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POST DATE 8/14/2016
END DATE 11/10/2016

AppleOne Jacksonville, FL

Company
AppleOne
Job Classification
Full Time
Company Ref #
23095259.1194
AJE Ref #
575880292
Location
Jacksonville, FL
Job Type
Regular
Required Licenses/Certifications
df-aj

JOB DESCRIPTION

APPLY
Pre Service

Call center inbound telephone queue service center position supporting Florida Blue's Pre Service Medical Review Team

Assist providers with the entry and update of requests for medical clearances

Research, coordinate and resolve inquiries and claims exceptions

Coordinate with other Provider Service areas to identify formal education opportunities

Identify, document and monitor process improvements



Post Service

Research and triage claims and inquiries prior to forwarding to clinical nurse for review



Care Programs

Data entry into Care Platform (e.g., authorizations and/or cases

Distribute case work/census, etc. to clinical nurse



Appeals

Data entry of appeals

Reviews appeal requests from members and providers in accordance with Florida Blue policies and procedures, regulatory guidelines and timelines.

Resolves grievances, appeals or disputes involving expressions of dissatisfaction, reimbursement, medical necessity, Claims Xtend, Utilization Management, and Fee for Service payments within regulatory timeframes for all lines of business with some exceptions.

Ensures final determination with statement that supports determination is communicated to the member and/or the provider in required timelines.

Send decision letters to members and providers
Maintains Personal Health Information (PHI) confidentiality

The job title that typically fills this role is an Service Advocate IV - Clinical Support, Service Advocate V - Clinical Support, Associate IIIb - Appeals and Admin Support (HEDIS/STARS)
Requirements:

High School diploma or equivalent

2+ years experience in health insurance, provider's office (handling medical coding, filing insurance claims or referrals) or a managed healthcare inbound telephone queue service center

Experience working with healthcare products including researching and resolving provider inquiries and working with provider contracts and networks

Experience working with medical terminology, CPT-4 coding, ICD-9 coding and claims adjudication inquiry resolution processes and procedures

Experience working with MS Word and Excel

Successful performance on job related assessments

Requires 9:45 a.m. to 6:15 p.m. shift coverage
Ability to access and navigate through multiple system applications

Job Expectations:

Must be able to work non-traditional hours to meet the member?s availability and business needs. Non-traditional hours is defined as: Staff may need to be available upon occasion to work beyond the required hours, weekends and/or holidays.

Competencies:

Teamwork & Collaboration: Selflessly supports and contributes to direct and cross-functional teams.

Driving for Results: Focuses on ensuring attainment of objectives at the enterprise, business unit, organizational or team level. Sets stretch goals and steadfastly pushes self and others to achieve maximum performance.

Critical Thinking: Analytically considers data, circumstances and impact to business performance, employees and customers to draw logical conclusions, make recommendations, implement initiatives and solve problems. We are an equal employment opportunity employer and will consider all qualified candidates without regard to disability or protected veteran status.