Avēsis
Health Insurance
ProviderRelationsSolutionSpecialist
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“Provider Relations Solution Specialist at Avēsis. Skills: Claims Resolution, Provider Credentialing, Provider Relations. Investigate and resolve complex dental and vision claims by working with payers, providers, and internal teams. Conduct monthly root cause analysis on recurring claim issues and recommend process improvements”
What You'll Achieve.
Supports achievement of departmental operational, quality, and performance KPIs through consistent execution, collaboration, and accountability
Industry & Context.
Analytical and problem-solving skills; Troubleshoot complex issues; Problem solve and multi-task
Must maintain internet service that allows for completion of essential job duties without issue (50 Mbps download and 10-25 Mbps upload while hardwired and not on a VPN)
What They're Looking For.
Must Have
2+ years of experience in dental or vision claims resolution, medical billing, or provider credentialing support, Comprehension of Dental or Vision Terminology, High School Diploma or equivalent, 2+ years of experience in document management, technical writing, provider relations, or a similar role, 1+ years of experience Microsoft Office applications, including Word, PowerPoint and Excel including data analysis and spreadsheet management, ability to learn and use additional software programs and systems for data analysis and reporting, As this role is a remote role, you are required to maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 10 25 Mbps upload while hardwired and not on a VPN are sufficient.
Nice to Have
Knowledge of health plan operations preferred, Knowledge of provider/health plan contracts/agreements highly desired, Bachelor’s degree in business administration, Communications, Healthcare Administration, or a related field (or equivalent experience), 2+ years of Provider Relations or Member Engagement experience
What You'll Do.
Investigate and resolve complex dental and vision claims by working with payers
Conduct monthly root cause analysis on recurring claim issues and recommend process improvements
Research and resolution of claims check trace requests for both in and out of network providers
Partner with multiple cross-functional departments and vendors to resolve claims issues timely and efficiently
Maintain accurate documentation of claim activity and resolution steps in internal systems
Respond to inquiries within 3 business days
provide education and may research
and recommend resolution updates to assist with provider confusion or disputes
Assist in the collection of and verification of credentialing documentation from providers and facilities assigned to the Provider Relations Department
Regularly conducting outreach via phone and email to obtain missing or updated documents
Track outstanding credentialing items and follow up weekly to ensure timely submission
Support credentialing compliance by maintaining accurate and up-to-date provider records
How You'll Work.
Team & Collaboration
Collaborate with payers, providers, and internal teams to resolve claims; Partner with multiple cross-functional departments and vendors to resolve claims issues; Actively contributing to the overall success of the Provider Relations team; Collaborating with internal stakeholders; Ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties
Communication Scope
Excellent written and verbal communication skills with attention to detail; Ability to communicate clearly and professionally with providers and internal stakeholders; Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing
Process & Methodology
Ability to manage multiple projects simultaneously and meet deadlines
Full Job Description
# **Join us for an exciting career with the leading provider of supplemental benefits!** O**ur Promise** Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards. The Provider Relations Resolution Specialist plays a critical role in ensuring the effective resolution of complex dental and vision claims while supporting provider credentialing efforts through proactive outreach and document collection. This position requires strong analytical and problem-solving skills, attention to detail, and the ability to communicate clearly and professionally with providers and internal stakeholders. The ideal candidate brings experience in dental or vision claims, a collaborative and team-oriented mindset, and a passion for enhancing the provider experience within a growing and innovative organization. **Claims Resolution & Research (Primary 70%)** * Investigate and resolve complex dental and vision claims by working with payers, providers, and internal teams. * Conduct monthly root cause analysis on recurring claim issues and recommend process improvements. * Accountable for research and resolution of claims check trace requests for both in and out of network providers, accountable for the end-to-end process while collaborating with internal stakeholders. * Partner with multiple cross-functional departments and vendors to resolve claims issues timely and efficiently. * Maintain accurate documentation of claim activity and resolution steps in internal systems. * Demonstrates ownership of individual responsibilities while actively contributing to the overall success of the Provider Relations team. Supports achievement of departmental operational, quality, and performance KPIs through consistent execution, collaboration, and accountability. Responds to inquiries within 3 business days, provide education and may research, analyze, an
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