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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Our client is re-imagining skill-based education building the future of higher education. The platform educates young talent from remote India (tier - 2/3 cities/towns) on job-relevant skills and connects skilled graduates to jobs. With more than 200000+ users currently on the platform, it is growing exponentially. We are looking for the missionary talent to join us in the journey to transform higher education and build the university of the future.
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Spring BootDeveloped in formal collaboration with the University of Cambridge in May 2000, HeyMath! is an Ed-Tech company whose mission is to Raise the Game in Maths for school systems around the world. We do this using technology to deliver engaging teaching methodologies and personalised learning paths for students. HeyMath! has been successfully adopted by CBSE schools since 2004, with positive outcomes for the entire ecosystem.
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Follow CutshortShubham Vishwakarma
Full Stack Developer - Averlon