Responsible for reconciling eligibility and capitation payment’s from CMS and Health plans. Prepare capitation reports for delegated IPAs. Coordinate with finance to facilitate monthly capitation payments.
ESSENTIAL JOB FUNCTIONS:
1. Serve Capitation processing: including cap deductions, flat capitation payments, monthly capitation compile, posting, and analysis, audit IPA capitation report and make sure the rates are according to the PCP contracts.
2. Assume day-to-day administrative responsibilities related to Eligibility.
3. Contact various health plans to verify member eligibility with the plans and IPA’s.
4. Maintain data from Health Plan either through website, discs and any other ways data is transmitted.
5. Monthly rejects and conflicts for members that needed to be added and termed in the system for monthly capitation run.
6. Assists the Claims Department to verify eligibility and other health coverage from the health plans.
7. Assists with daily phone queue from providers, members and vendors related to eligibility and capitation.
8. Manually input new providers’ membership not on E-list.
9. Fixes EDI errors of “Member Can’t Find”.
· High school graduate or equivalent.
· 2 yrs. EZ-Cap exp
· Knowledge of managed care and HMO products
· Proficient in Microsoft products specially in Excel
· Handles phone calls professionally and courteously
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