Oversees the daily operations of the unit for assigned staff in the unit. Serves as a leader and back-up for assigned staff in the unit. Coordinates workload and provides assistance on complex cases that require special expertise in the unit so that they are resolved in a timely manner. Complies with all laws and regulations associated with duties and responsibilities.

• Manages People
• This role directly manages 12 workers
• This role directly manages these jobs: PROVIDER DISPUTES SPECIALIST
• This role reports to this job: MANAGER, Medical Coding
• Necessary Contacts: In order to effectively fulfill this position, this position must be in contact with:
  
  Various internal and external entities including, but not limited to, all levels of BCBSLA personnel, attorneys, group leaders, members, hospitals, physician offices, and DOI.

• High School Diploma or equivalent required
• Bachelor's degree in a related field preferred

• 5 years of insurance experience to include experience in disputes, appeals and grievances, adjustments and customer service and one year of demonstrated leadership experience. Experience can run concurrently required
• 2 years of leadership experience preferred.

• Must be able to read and interpret benefits for all lines of business.
• Must be able to read and interpret all provider contracts and manuals.
• Must be knowledgeable and able to provide technical guidance on claims processing and complex appeals functions and cases.
• Demonstrated knowledge of accreditation guidelines, state laws, and relevant PC software which includes Facets, Epic, MS Word, Query Tools, Excel and Outlook is preferred
• Requires attention to detail and excellent record-keeping skills. Must demonstrate the ability to work in a rapidly paced and ever-changing environment.
• Able to make decisions, prioritize, find solutions and work independently.
• Strong analytical and organizational ability and verbal and written communication skills are required.
• Must have excellent time-management and interpersonal skills to respond to numerous inquiries in a diplomatic and timely manner.
• Presentation and public speaking skills are required.

• None Required

• Administers all HR functions, including but not limited to, hiring, terminating, conducting performance reviews, setting performance standards, approving work schedules, assigning and directing workload, training and developing staff, coaching, etc. to ensure team goals are met.
• Serves as the subject matter expert to ensure accurate and timely handling of all cases. Maintains thorough knowledge of all contract types, changes to recent laws and regulations, computer systems and claims policies and procedures to ensure consistency in processes and responses.
• Motivates, coaches, audits and trains staff by answering questions, providing technical assistance, reviewing case files and letters to ensure deadlines are met and compliance with company policy, laws and regulations are maintained.
• Identifies and reports weekly trends in production, inventory levels, and performance statistics.
• Interfaces with providers to promote education, consistency and satisfaction.
• Coordinates the daily workflow to ensure compliance with established internal and external policies and procedures to ensure timeframes are satisfied.
• Assists in the development of departmental policies and procedures. Makes complex decisions involving consumer and provider contracts to ensure compliance with state and federal regulations, accreditation and business practices.
• Familiar with the many differences in the Self Funded block of business and our fiduciary responsibility and requirements.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.