AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Provider Contestment Reviewer in Miami and/or Gainesville, Florida. This is a hybrid position, 2 days in office and 3 days remote.

Scope of position: The Provider Contestment Reviewer is responsible for processing claims that have been paid in excess of AvMed’s contractual obligation.  Make adjustments and/or send correspondence when necessary.

Essential Job Functions:

Monitor aging of provider overpayments/receivables. Develop and execute strategies to recoup the funds from the providers. Work with Network and external agencies to recoup uncontested aged receivables.Ability to review, process, register and post in HRP all types of checks (solicited and unsolicited).Review and process contested overpayment letters/claims.Interpret and apply AvMed’s policies and claims administration procedures.Ability to work and report results of overpayment projects.Meet the department’s production and quality standards. Focus on achieving departmental and organizational objectives.Identify and report system and configuration issues.Complies with company policies and procedures, which includes dress code, punctuality as they relate to work time, lunch, and break periods.Must have the ability to effectively communicate both verbally and in writing with providers for the purpose of adjustment, as well with members regarding retroactive terminations.Performs additional duties and responsibilities as assigned by management.

Minimum Requirements:

High School diploma requiredAssociate in business or any related field preferred3-5 years of experience in a complex managed care environment with multiple products and entities, with an emphasis in claims, pricing and/or benefits within healthcare. Previous audit or system configuration experience preferredAn equivalent combination of education and experience may be considered

Preferred Requirements:

Strong verbal and written communication skillsStrong analytical and interpretative skillsExcellent organizational skillsEffective problem-solving skills and ability to handle simple and complex tasks.Detail-oriented skills to adapt to various workflows, multiple tasks, deadlines and changing prioritiesMedical Coding including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-10) and Diagnosis-related Group (DRG) CodesHRP, MACESS, or Similar Software SystemsMicrosoft Office Suite (Word, Excel, Access)

Our Benefits:

As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers.  We offer a variety of amenities to our employees, including, but not limited to:

Medical, Dental, and Vision InsurancePaid Annual Leave, Sick LeaveFlexible Spending Accounts Retirement funds with matching contributionSupplemental insurance policies, including legal, Life Insurance and AD&D among othersWork Perks program including discounted movie and theme park tickets among other great deals Opportunities for further advancement within our organization

Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace.  For information about our employee benefits, please visit: Benefits – Sentara (sentaracareers.com)

Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, and growth!

Note: Sentara Healthcare offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.

Keywords: Talroo-Health Plan, #INDEED, Claims, Pricing and or Benefits

The primary role of the Provider Data Enrollment Specialist I is to ensure the data integrity of provider records entered and maintained in the credentialing and/or payment systems. This position may be responsible for all aspects of ensuring accurate and timely processing of provider setup to initiate credentialing, provider record updates and edits, processing provider terminations, and researching and resolving provider setup issues in the applicable systems. This data maintenance will support network adequacy and growth, regulatory reporting, provider directories, as well as downstream systems and processes. Minimum of 1-year experience in healthcare insurance working with provider, network, or contract data; or a combination of education and experience, which would provide an equivalent background Understanding health claims processing is a plusHigh School Grad or EquivalentInsurance 1 year