MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

This position is responsible for the accurate and timely response to written claim inquiries received from BH providers. Incumbent provides support regarding the adjudication and adjustment of claims for the multiple lines of business. The incumbent works closely with Provider Relations, Medical Management, Member Services, and the Claims Processing unit..

• Act as a key liaison and service representative for all written provider inquiries and problem resolution.
• Respond to all claim inquiries from provider sites personnel including physicians, clinical staff, and site administrators.
• Coordinate and track appropriate problem resolution activities with plan personnel in other departments (i.e., claims, utilization management)
• Manage and ensure appropriate follow-up and closure for all inquiries.
• Respond to Provider Inquiries in writing; maintain accurate files.
• Data Entry into the PowerStepp system.
• Perform claim adjustments to correct erroneous payments (overpayments/underpayments).
• Participate in Special Projects involving Claim Status Investigations.
• Resolve Member Bills referred from Member Services.

• Associates Degree from an accredited college or university
• Minimum 3 years of customer service experience in a managed care or hospital organization
• Thorough knowledge of Plan Benefits.
• Proficiency in PowerStepp system.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

#LI-Hybrid

• Must be able to handle provider inquiries in a professional manner.
• Excellent written/verbal communication skills.