Employment Type:

Full time

Shift:

Description:

Why MediGold?

MediGold (https://medigold.com/) is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

We know that exceptional patient care starts with taking care of our colleagues, so we invest in great people and all that we ask in return is that you come to work ready to make a difference and do the right thing.

Position Purpose:

The Operations Resolution Specialist researches, analyzes, documents, and coordinates the resolution of escalated and/or complex issues pertaining to claims, member services, network operations and RAPS and EDPS submissions. Serves as a department subject matter expert and requires knowledge of all Plan systems, tools, policies and procedures.

Minimum Qualifications:

• Education: Associate or Bachelor's degree preferred.

• Licensure / Certification: Claims department: CPC, CPC-P or equivalent required. Member Services department: Active State of Ohio Insurance License (Life and Health) or obtained within 90 days of hire. Risk Adjustment department: None

• Experience: One to three years experience preferred in either managed care health insurance, or customer service disciplines

• Knowledgeable in provider coding and billing requirements

• Knowledgeable with provider credentialing and contracting terminology

• Basic knowledge of the healthcare claims process

• General knowledge of current medical terminology, anatomy and physiology

What you will do:

• Responds to sensitive, escalated and difficult inquiries. Researches, resolves and responds to such inquiries in a timely, compliant and courteous manner.

• Determines trends and provides education and feedback related to escalated questions and issues.

• Coordinates the identification of root causes for errors and works with multiple operational areas across the Plan to fully resolve identified errors.

• Generates reports as necessary to monitor processes.

• Assists in the development and maintenance of department policies and procedures.

• Functions as a team member by serving as a department resource and subject matter expert

• Assists in the development of tools and presentations on documentation, coding, billing, and other requirements necessary for complete encounter data submissions

• Works proactively with external vendors to troubleshoot encounter errors and correction of necessary inbound data

Position Highlights and Benefits:

• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.

• Retirement savings account with employer match starting on day one.

• Generous paid time off programs.

• Employee recognition programs.

• Tuition/professional development reimbursement.

• Relocation assistance (geographic and position restrictions apply).

• Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing.

• Employee Referral Rewards program.

• Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day!

• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

Ministry/Facility Information:

Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our four hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohio's largest undergraduate, graduate, and doctor of nursing programs. If you’re seeking a rewarding career where your purpose, passion, and desire to make a difference come alive, we invite you to consider joining our team. Here, care is provided by all of us For All of You!

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Mount Carmel and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, physical disability or any other classification protected under local, state or federal law.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran