Role Description Investigate, evaluate, negotiate, and resolve workers’ compensation claims with minimal supervision. - Conduct interviews with injured employees, store personnel, and medical care providers within 24 hours of receiving reported incident. - Utilize complex problem solving, critical thinking skills, and strong organization skills to timely evaluate compensability and management of claim assignments. - Maintain communication with appropriate parties throughout life of file for proper medical and disability management and resolution. (20%) - Utilize professional experience and investigative skills to evaluate monetary exposure of claim and ability to establish action plan to include medical, disability management, and resolution. (20%) - Proactively and timely coordinate and communicate with doctor, injured employee, and store personnel for light duty or full duty return to work, payment of appropriate benefits, and properly utilize in-house and field nurse resources for medical and disability management. (15%) - Ability to timely evaluate requests for medical care regarding causation and relatedness and in compliance with state requirements. - Timely evaluate and pay medical and indemnity benefits in accordance with the law. Complete appropriate state reporting. (15%) - Coordinate and communicate with service providers such as defense attorneys, medical case managers, and private investigators to minimize claim expense and maximize results. (10%) - Develop and maintain a proactive strategic plan of action for the life of the file and resolve claims and make recommendations for claim resolution efficiently and within best practice expectations, and state requirements. (10%) - Maintain a working knowledge of multiple state workers’ compensation laws and statutes and maintain appropriate state required licensing. (10%) Qualifications - Extensive claim handling experience with emphasis on workers’ compensation. - Possess complex problem solving and strong decision-making skills. - Strong organizational skills and the ability to prioritize. - Customer service oriented and works well in a team environment. - Excellent written and verbal communication skills. - Must be detail oriented and able to meet deadlines. - Ability to handle confrontational situations in a mature and professional manner. - Working knowledge of medical and legal terminology. - Working knowledge of Microsoft Office programs. Requirements - Extensive insurance claims background and experience with emphasis on workers’ compensation. - 1-2 years of related experience preferred. - College degree preferred but not required. - Equal education and experience may be considered. Benefits - This is a Remote role with a base compensation of $67,000.

Role Description Under the general supervision of the Director of Managed Care Operations and the direct supervision of the Credentialing Administrator, the Credentialing and Impaneling Specialist performs tasks to ensure that all DWIHN practitioners and provider organizations are credentialed prior to performing services in the DWIHN system. The Credentialing Specialist also ensures healthcare professionals and facilities meet all established federal and state standards, as well as NCQA (National Committee for Quality Assurance) standards. - Completes review of provider credentialing and re-credentialing applications checking for completeness and accuracy. - Prepares reports for the Credentialing Committee on provider file status. - Completes National Practitioner Database Check, Systems for Award Management database check, MDHHS Sanctioned Providers List, and OIG checks as appropriate. - Maintains, tracks and monitors the expiration dates of SAM Registration, accreditation, and license expiration and notifies providers as needed. - Manages the Credentialing process using the Medversant system. - Serves as the primary contact for the Managed Care Operations unit for Medversant and other Credentialing provider inquiries. - Provides instruction and training to the DWIHN Provider Network on the Credentialing process. - Responds to all Provider Requests for new applications and questions regarding the Credentialing process. - Provides status updates for providers and practitioners. - Assists in updating policies and procedures for the Credentialing process. - Completes Readiness Reviews of Providers upon request. - Maintains database of approved services to determine the capacity of the Provider Network. - Prepares and sends approval letters to providers. - Collects and processes verification and accreditation information. - Updates and maintains accurate databases for facilities and practitioners. - Attends Credentialing Committee, subcommittee and other meetings. - Maintains confidentiality of all Provider/ practitioner information. - Performs related duties as assigned. Qualifications - Knowledge of DWIHN policies, procedures and practices. - Knowledge of the DWIHN provider network and community resources. - Knowledge of the Michigan Mental Health Code. - Knowledge of MDHHS policies, rules, regulations and procedures. - Knowledge of Federal policies, rules, regulations and procedures as it relates to DWIHN. - Knowledge of Credentialing principles and practices. - Knowledge of the Medversant software system. - Knowledge of MHWIN. - Knowledge of compliance standards. - Knowledge of NCQA requirements and the accreditation process. - Assessment skills. - Evaluation skills. - Organizational skills. - Interpersonal skills. - Communication skills. - Computer skills (Word, Excel, Access, Power Point, Outlook, Teams). - Teamwork skills. - Ability to communicate orally. - Ability to communicate in writing. - Ability to work effectively with others. - Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population. - Judgement/Reasoning ability. Requirements - A High School Diploma, a GED or its equivalent. - Four (4) years of full-time paid professional experience performing administrative duties and responsibilities. - One (1) year of full-time paid professional experience performing credentialing and impaneling duties and responsibilities. - A valid State of Michigan Driver’s License with a safe and acceptable driving record. - Certified Provider Credentialing Specialist (CPCS) certification is preferred, not required. Working Conditions Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. This position can work remotely with supervisory approval. Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process. The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer.

Role Description The Copay Claims Processor is a member of the TailorMed Complete team and serves as an extension of our customer’s internal teams. In this role, you'll help improve financial outcomes for patients by using our platform to submit claims on the patient’s and provider’s behalf to the approved manufacturer or foundation copay program, and for our customers by helping them improve their financial performance as an organization. - Ability to review pending claims thoroughly in detail to ensure accuracy - Submit copay claims through appropriate channels, including follow through to payment posting - Conduct timely follow up to check for claims status - Work closely with the Financial Navigation team to ensure accurate and timely processing of claims - Claim denial review and understanding in how to evaluate for next steps - Conduct outbound calls with manufacturer copay programs and foundation copay programs to resolve any issues or discrepancies - Conduct outbound calls effectively with customer’s revenue cycle department to resolve any issues or discrepancies - Post claim payments accurately and appropriately as received - Maintain accurate records of all claims processed - Meet productivity and quality standards Qualifications - 2+ years of experience in medical billing and coding, or financial navigation experience - Ability to work effectively in a remote environment - Experience working within EMRs and Billing Systems - Experience working with insurance providers and healthcare organizations - Knowledge of all insurance types - Excellent communication and organizational skills - Ability to work well in a fast-paced environment - Willingness to adhere to and work during customer’s business hours - High school diploma or equivalent required - Workspace clear of noise and ability to work with PHI in a secure setting Benefits - Competitive salary + equity - Premium medical, dental, and vision insurance plans, a wide range of voluntary and supplemental benefits, and 24/7 benefits access and support - 401(k) plan - Paid holidays, vacation, and sick leave - Six weeks of paid parental leave - Company-paid life insurance - Company provided equipment and technology you’ll need to be successful in your role - The opportunity to help shape the future of healthcare

Role Description The claims resolution representative plays a vital role in ensuring accuracy and adherence to the applicable guidelines. This position serves as a crucial liaison between members, providers, agencies, and the internal claims department, demonstrating leadership, collaborative skills, and commitment to achieving results. - This position is remote within the United States, but applicants can expect to work Eastern Time regular business hours with some flexibility. Responsibilities: - Independently resolve suspended claims using the resolution screens in accordance with operational procedures and process recoupments. - Determine when to use a "Forcible" disposition to override the edit and process the claim based on operational claims adjudication procedure. - Review and analyze claims and follow up on the status of claims and reimbursement. - Interpret and apply policy and reimbursement rules to support provider inquiries. - Ensure accuracy and consistency in claims processing. - Research and review submitted claims (electronic) and process them according to policies and procedures. - Possess an unwavering commitment to customer service and operational excellence. - Perform manual pricing and audit checks to ensure compliance with policies and rules. - Review and process suspended claims and submitted documentation. - Provide sufficient detail to explain claims denial reasons. - Implement workflow processes and capabilities for work queues with the ability to route workstreams. - Approve or deny requests for transportation authorization from providers, verify member transportation claims, and process approved claims. - Perform manual reviews on claims, documents, and attachments. - Release individual claims for providers on review. - Independently resubmit claims with applicable corrections. - Independently address discrepancies in charges, payments, adjustments, and demographic information. - Facilitate manual entry of claims into the system. - Review paper claims and attachments, scanning them using scanning equipment to attach the documents to corresponding transaction control numbers. - Other duties as assigned. - Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules. Qualifications - High School Diploma or GED - 1+ years of experience conducting research to resolve issues within the healthcare field Requirements - Ability to maneuver through various computer claims and eligibility platforms simultaneously - Outstanding customer satisfaction skills - Must be firm but professional when interacting with contacts while performing tasks - Friendly personality, tact, patience, empathy, and a helpful yet professional attitude are essential - Strong computer skills, including proficiency in MS Word and Excel - Excellent oral and written communication skills - Excellent organization and time management skills, with the ability to establish priorities effectively - Ability to read, write, and follow directions - Self-directed and capable of working without direct supervision - Ability to collaborate effectively with others - Create and maintain a positive atmosphere, demonstrating leadership qualities - Knowledgeable in claims review and analysis