Provider Reimbursement Specialist, Fee Schedules

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Cultivates and maintains relationships with physicians, hospitals, ancillary providers, and Fidelis' internal Provider Network Management Department.

• Serves as the primary contact for providers and hospitals regarding claims projects and other non-standard claim issues.

• Manages the resolution of project-related issues in collaboration with Adjustment and New Day Unit Supervisors.

• Communicates the final resolutions to providers, hospitals, business units, and management teams.

• Aids in interpreting policies and procedures.

• Investigates, analyzes, and resolves intricate problems related to claims development and finalization.

• Provides assistance with complex claim issues and large-scale projects.

• Oversees projects with designated adjusters and/or regional units for research, analysis, and resolution.

• Directly responds to providers with final resolutions, including root-cause documentation, corrective action plans, and initiatives for process improvement.

• Conducts regular site visits to providers, physicians, and facilities.

• Engages with Network Management in Joint Operating Committees.

• Coordinates corrections to contract data with Provider Network and Provider Data Management.

• Identifies contracting opportunities through root-cause analysis.

• Interprets Health Net policies and procedures related to claim issues, contracts, and benefits.

• Collaborates with Provider Network Management when issues cannot be resolved with providers and internal departments.

• Participates in process improvement initiatives and facilitates corrective actions.

• Prepares monthly reports for management documenting issues, action plans, and resolutions.

• Investigates and addresses Shared Risk Discrepancies from Participating Provider Groups.

• Performs other assigned duties as necessary.

• Adheres to all policies and standards.

⛳️ Requirements

• Must be legally authorized to work in the U.S. without requiring employment-based visa sponsorship now or in the future.

• Bachelor's degree in Health Services, Health Care/Hospital Administration, a related field, or any combination of education and/or work experience providing an equivalent background is required.

• At least two years of experience in medical claims review and/or claims appeal is required.

• Familiarity with New York state provider fee schedules is preferred.

• Experience with independent dispute resolution (IDR) related to the No Surprises Act is preferred.

• Experience in monitoring rate updates and changes is preferred.

• Proficiency in claims analysis is preferred.

• Candidates residing in the Tri-state area (NY, NJ, CT, PA) are preferred.

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work arrangements with remote, hybrid, field, or office schedules.

• Additional incentive options may be included in the total compensation package.

• Equal opportunity employer committed to fostering diversity.