Provider Relations Specialist I

<strong>AF Group (Lansing, Mich.) and its subsidiaries are a premier provider of innovative insurance solutions. Insurance policies may be issued by any of the following companies within AF Group: Accident Fund Insurance Company of America, Accident Fund National Insurance Company, Accident Fund General Insurance Company, United Wisconsin Insurance Company, Third Coast Insurance Company, or CompWest Insurance Company.</strong>

Lansing, USA

AF Group

<p class="p1"><strong>AF Group&rsquo;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.</strong></p> <p class="p1"><strong>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.</strong></p>

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Competitive Compensation and Benefits Package

Overview: <p><strong>WAIVER OF QUALIFICATIONS IS being made for this posting only and without precedent for future postings.&nbsp;</strong></p> <p><strong>SUMMARY:&nbsp;</strong></p> <p><strong>We are conditionally waiving certain requirements for this posting only (See below).</strong></p> <p><strong>Provider Relations Specialist I:</strong></p> <p>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.</p> <p><strong>Provider Relations Specialist II:</strong></p> <p>Responsible for analyzing billings including outpatient hospital and multiple surgeries by utilizing our Medical Bill Review (MBR) software and reference library to determine appropriateness of codes and excessive charges. Responsible for making coding determinations according to state rules and regulations.<br /><br /><br /></p> <p><strong>WORKING CONDITIONS:</strong></p> <p>Work is performed in an office setting with no unusual hazards.</p> <p>&nbsp;</p> <p><strong>REQUIRED TESTING:</strong></p> <p>Proofreading, 10-Key, Math, Basic Windows, Reading Comprehension, Typing 40wpm, Intermediate Word, Intermediate Excel</p>
Responsibilities: <ul> <li>Utilizes ACD phone lines to manage incoming calls and inquiries.</li> <li>Provides high level of customer service for all internal or external customers thru telephonic, email and fax.</li> <li>Demonstrates dependable work ethic.</li> <li>Manages confidential client information with discretion and good judgement in accordance with department and company guidelines.</li> <li>Identifies problems, provides solutions and resolves promptly, escalating more complex problems appropriately.</li> <li>Responds to written or verbal provider inquiries relating to our bill review analysis.</li> <li>Analyzes problems using problem solving methodology skills to determine root cause; communicates and implements solutions.</li> <li>Types, photocopies, faxes as necessary.</li> <li>Create reconsiderations for processing.</li> </ul> <br /> <p><strong>Additional responsibilities of Provider Relations Specialist II:<br /><br /></strong></p> <ul> <li>Responsible for performing technical review of more complex medical bills, including but not limited to modifiers, anesthesia, &amp; psychiatric.</li> <li>Responsible for analyzing complex billings for multi-state Workers Compensation medical claims to determine appropriateness of services billed.</li> <li>Responsible for making bill review processing determination according to rules and regulations and/or third-party partner.</li> <li>Evaluates medical bills and corresponding EOR&rsquo;s for accuracy and compliance with state mandate fee schedule(s) and our business rules and guidelines.</li> <li>Reviews inpatient hospital, outpatient hospital, and multiple surgery billings.</li> <li>Reviews, analyzes, adjusts and releases queued bills in an accurate and timely manner.</li> <li>Refers to reference library of fee schedules, CPT, ICD-CM, HCPCS, and other industry publication to support findings.</li> <li>Processes reconsiderations, as needed.</li> <li>Phone backup to Provider Relations Team as may be needed.</li> </ul> <br /> <p>This description identifies the responsibilities typically associated with the performance of the job. The percentage of time in any responsibility may vary between positions. Other relevant essential functions may be required.</p>
Requirements: <p><strong>EDUCATION REQUIRED:&nbsp;</strong></p> <p><strong>Provider Relations Specialists I:<br /><br /></strong></p> <ul> <li>High School Diploma or G.E.D. required.</li> <li>Completed coursework or enrolled in Medical Insurance Billing and Coding.</li> </ul> <br /> <p><strong>Provider Relations Specialists II:<br /><br /></strong></p> <ul> <li>Certificate in Medical Billing, required.</li> </ul> <br /> <p><strong>EXPERIENCE REQUIRED:&nbsp;</strong></p> <p><strong>Provider Relations Specialists I:<br /><br /></strong></p> <ul> <li>Minimum three years of general office experience including a minimum of one year in workers&rsquo; compensation insurance. Prior experience answering inquiries over the phone or equivalent relevant experience that would provide the required skills, knowledge, and abilities. Relevant customer service experience exchanging information and answering basic inquiries over the phone is required.</li> </ul> <p><strong>OR</strong></p> <ul> <li>Minimum of four years of general office experience. Two years of customer service experience answering inquires over the phone in an insurance organization. Prior equivalent relevant experience that would provide the required skills, knowledge, and abilities may be considered.</li> </ul> <p>&nbsp;</p> <p><strong>Provider Relations Specialists II:<br /><br /></strong></p> <ul> <li>Two years as a Provider Relations Specialist I.</li> </ul> <p><strong>OR</strong></p> <ul> <li>Three years experience in an insurance organization with two years demonstrated technical knowledge in workers&rsquo; compensation medical bill review or other relevant experience, which provides necessary skills, knowledge, and abilities.</li> </ul> <br /><br /> <p><strong>Temporary Change to Experience Requirement for Provider Relations Specialist II:</strong></p> <ul> <li><strong>90 Days as a Provider Relations Specialist I, with the successful completion of the Training Program, will qualify the candidate to become a Provider Relations Specialist II</strong></li> <li><strong>Training Program consists of the following bill subsets: Data Entry by bill type, Technical Review, Level of Service, Surgery and Facility</strong></li> <li><strong>Success of Training Program will be determined by a &ldquo;Satisfactory&rdquo; on the 30/60/90 Day Probationary Time Period.</strong> <ul> <li><strong>Expectations will be set for each 30-day&nbsp;interval to include:</strong> <ul> <li><strong>Demonstrated understanding of training topics</strong></li> <li><strong>Continued improvement with production and quality</strong></li> <li><strong>Ability to work in a fast-paced&nbsp;environment</strong></li> </ul> </li> </ul> </li> <li><strong>Phone Training will commence after the successful completion of the Training Program as described above.</strong></li> </ul> <p><strong><br /><br />NOTE: This temporary change is not to extend beyond filling of open vacancies as of 08/29/2023. Once the vacancies are filled this temporary change is suspended unless mutually agreed between the parties to extend the timeframe.</strong></p> <p>&nbsp;</p> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:&nbsp;</strong></p> <p><strong>Provider Relations Specialists I:<br /><br /></strong></p> <ul> <li>Excellent customer service skills.</li> <li>Excellent telephone etiquette.</li> <li>Knowledge of multi-functional phone system.</li> <li>Ability to obtain pertinent and thorough information from customers.</li> <li>Knowledge of computers and spreadsheet software.</li> <li>Ability to type 40 wpm accurately.</li> <li>Ability to proofread documents for accuracy of spelling, grammar, punctuation, and format.</li> <li>Ability to perform mathematical calculations with the ability to use a ten-key pad with accuracy.</li> <li>Ability to multi-task, i.e., interact on telephone while entering data.</li> <li>Ability to manage work with minimal direction.</li> <li>Excellent oral and written communication.</li> <li>Demonstrate attention to detail.</li> <li>Ability to consistently meet or exceed daily production and quality standard for this position.</li> </ul> <p>&nbsp;</p> <p><strong>Additional Skills Required for Provider Relations Specialist II:<br /><br /></strong></p> <ul> <li>Working knowledge, experience, and ability to process bills using state medical payment methodologies.</li> <li>Ability to use independent discretion to make choices on proper reimbursement.</li> <li>Thorough knowledge of Workers' Compensation multi-state medical fee schedules, Medical guidelines, medical terminology and CPT/ICD-CM.</li> <li>Basic knowledge of Workers' Compensation Act.</li> </ul> <p>&nbsp;</p> <p><strong>ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED:</strong><em>&nbsp;<br /><br /></em></p> <ul> <li>Background in Workers' Compensation preferred.</li> <li>Degree or Certification in Medical Coding.</li> <li>Experience with an ACD telephone system.</li> </ul>