commercial, federal and state government plans specifically support operational
processes for provider data management functions, enrollment and eligibility,
member benefits, claims adjudication and EDI Interfaces functions.
• Knowledge of State regulations to determine provider meets qualification to be
enrolled.
• Knowledge of provider files from State Medicaid programs to decipher provider
enrollment and eligibility rules.
• Knowledge of provider type designation identified by the State Medicaid programs.
• Knowledge of provider and member portal functions.
• Knowledge of provider reimbursement methodologies about Commercial, CMS and
State defined guidelines.
• Knowledge of provider matching criteria for claims.
• Knowledge of Coordination of Benefits (COB) and Claim Authorizations functions.
• Knowledge of Setting up communications for EDI transmissions using FTP, SFTP and
real time API setups
• Knowledge of health insurance, HMO and managed care principles including
Medicaid and Medicare regulation.
• Solid analytical skills with the ability to compile data from many sources and define
designs for enrollment to benefit plan configuration.
• Research, interpret and summarize new state, federal and client rules regarding
department functions. Alter or create policies and procedures to adhere to those
rules.
• Solid communication skills with working session facilitation.
• Strong time management, attention to detail, analytic and organizational skills.
• Excellent interpersonal, oral and written communication skills.
• Able to work independently and within a collaborative team environment with little
guidance/supervision.
Shubham Vishwakarma
Full Stack Developer - Averlon
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Follow CutshortShubham Vishwakarma
Full Stack Developer - Averlon