REPORTS TO: Network Services Manager/Supervisor LOCATION:
Missoula FLSA STATUS: Non-Exempt
The Network Services EDI Specialist is responsible for the accurate and timely importing/exporting of electronic claim files into our claims system.
Be responsible for the accurate repricing of claims according to PPO contract provisions, and all support functions necessary to secure correct discounts and provide requested information.
The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and to be respectful and courteous in the conduct of this position.
ESSENTIAL JOB FUNCTIONS:
Essential job functions include the following. Other functions may be assigned as business conditions change.
Import/Export EDI files on a daily basis (electronic claim files)
Trouble shoot errors on EDI files so the files will load accurately
Review claims from imported files in claim system
Interprets/Add provider network contracts for different in house CSN's (client specific network)
Responds to claims pricing and general CSN inquiries from plan participants, providers, networks, claims examiners, and customer service representatives.
Updates provider addresses in the claims processing system.
Contributes to the daily workflow with regular and punctual attendanc
NON-ESSENTIAL JOB FUNCTIONS:
PHYSICAL WORKING CONDITIONS:
Physical requirements are representative of those that must be met to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
High (visual acuity corrected to 20/30)
up to 30 pounds
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals
with disabilities to perform the essential functions.
Minimum Education: High school graduation or GED required. College degree and/or training in medical terminology preferred.
Certification(s) Required: None.
Minimum Experience: Previous experience with computer software applications is required. Work experience with group health benefits or in the health insurance industry preferred.
Excellent oral and written communication skills required.
PC skills, including Windows, Excel, Access, Word, internet navigation, and email applications. Ability to learn all functions of the claims processing software as is necessary for data entry, research and report generation. Must be able to adapt to software changes as they occur.
Accurate data entry and typing skills.
Knowledge of medical terminology, basic health insurance concepts and repricing systems.
Excellent listening skills.
Basic mathematical skills. Ability to calculate and obtain correct discounts from providers as stipulated by contract.
Ability to gain thorough knowledge of managed care systems, contracting, and health care economics.
High level of interpersonal skills to work effectively with others.
Ability to organize and recall large amounts of detailed information.
Ability to project a professional image and positive attitude in any work environment.
Ability to comply with privacy and confidentiality standards.
Ability to be flexible, work under pressure and meet deadlines.
Ability to analyze and solve problems with professionalism and patience, and to exercise good judgment when making decisions.
Ability to take initiative and work independently.
Ability to operate typical office equipment.
Working knowledge of general office procedures.
The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel as classified.