Associate II, BPM

About the Role

The Provider Inquiry Specialist professional is responsible for processing and resolving healthcare provider inquiries related to claims, eligibility, benefits, authorizations, denials, adjustments, and payment details. The role requires strong analytical ability, attention to detail, process adherence, and effective written communication while meeting SLA, TAT, quality, and compliance requirements.

Key Responsibilities

• Review and process provider inquiries received through ticketing, workflow, or portal-based systems such as PEAR and OneHub.
• Investigate inquiries related to claim status, payments, eligibility, benefits, authorization status, denials, and adjustments.
• Research claim and provider information using payer systems and supporting applications to determine the appropriate resolution.
• Provide accurate, clear, and professional responses to healthcare providers.
• Route cases to appropriate internal teams for corrections, adjustments, or additional investigation when required.
• Accurately document case details, actions taken, and resolutions in the appropriate tracking or case management system.
• Meet defined SLA, TAT, productivity, and quality targets.
• Support backlog and aging management by prioritizing cases based on business requirements.
• Participate in quality reviews, feedback sessions, calibrations, and cross-audits.
• Follow established SOPs and process guidelines and identify opportunities for continuous improvement.
• Maintain compliance with HIPAA, organizational policies, and client-specific requirements.

Tools & Systems

• PEAR Portal / PPM
• OneHub / Pulse or similar workflow and ticketing applications
• Healthcare claims processing systems
• Aerial / CFI / Burgess / HealthRules or equivalent payer applications

Requirements & Tech Stack

• Knowledge of US Healthcare and healthcare BPM processes.
• Understanding of claims, provider inquiry, eligibility, benefits, and authorization workflows.
• Strong analytical and problem-solving skills.
• Good written communication skills.
• Strong attention to detail and documentation accuracy.
• Ability to manage high-volume transactional work while maintaining quality.
• Ability to work effectively within defined SLA and TAT requirements.
• Ability to adapt to changing priorities and business requirements.

Preferred Skills

• Previous experience in Healthcare BPM, Provider Inquiry, Provider Services, or Claims Operations.
• Experience handling claim denials, adjustments, pricing, eligibility, benefits, and authorization inquiries.
• Knowledge of healthcare terminology such as EOB, CPT, ICD, deductible, copay, and authorization.
• Experience working with payer-side healthcare processes is preferred.

Key Performance Indicators

• SLA and TAT adherence
• Productivity
• Quality and accuracy
• Provider response accuracy
• Backlog and aging management
• Process and compliance adherence

UST Values

Candidates are expected to demonstrate:

• Humility: Respectful collaboration and openness to feedback.
• Humanity: Empathy toward customers, providers, members, and colleagues.
• Integrity: Ethical processing and adherence to compliance requirements.
• Customer Focus: Delivering accurate and timely outcomes aligned with client expectations.
• Excellence: Continuous improvement, accountability, and ownership of results.

Skills

• HIPAA
• Healthcare Systems
• Claims Management
• Business Operations