Claims Provider Service Advocate

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The Claims Provider Service Advocate will serve as a subject matter expert for Long-Term Services and Support (LTSS) claims-related inquiries and escalations. This role is responsible for investigating, recovering, and resolving a broad range of LTSS claim issues, ensuring alignment with contractual, reimbursement, and compliance standards. The individual will analyze claim trends, prepare reports, and provide proactive support to the LTSS Provider Services and Relations Team.

This position requires solid analytical thinking, initiative, and the ability to work independently across multiple systems and applications. The ideal candidate is a self-motivated problem solver with a high attention to detail and a commitment to timely, high-quality service delivery. The Claims Provider Service Advocate will also facilitate quarterly claims clinics for providers to support education and prevention.

If you are located in Tennessee, you will have the flexibility to work remotely* as you take on some tough challenges.

• Investigate and resolve a variety of LTSS claim issues and escalations with accuracy and urgency
• Provide claims expertise and support to the LTSS Provider Services and Relations Team
• Research and analyze claims trends; compile reports and share findings with leadership
• Ensure adherence to reimbursement policies, contract terms, and state compliance requirements
• Support recovery and resolution efforts for the health plan
• Handle high-level provider escalations as needed
• Facilitate and lead quarterly claims clinics with providers to identify areas for improvement and provide education
• Work across multiple systems and functions daily, including CSP Facets and related tools

• 4+ years of experience in claims recovery and resolution
• Intermediate level of proficiency in CSP Facets
• Intermediate level of proficiency in Windows PC applications and the ability to learn new complex systems
• Reside in Tennessee
• Ability to travel to TN up to 10% for in-market team meetings as necessary

• Experience using: Maces OIT ORBIT Business Objects Production IMPACT Facets EchoUi Provider Information Queues (PIQ)
• Maces
• OIT
• ORBIT Business Objects Production
• IMPACT
• Facets
• EchoUi
• Provider Information Queues (PIQ)
• Experience supporting or collaboration with provider relations or external stakeholder teams
• Familiarity of LTSS programs

• Effective written and verbal communication and presentation skills
• Ability to balance multiple high priority projects and meet quick deadlines
• Proven solid analytical and problem-solving skills
• Proven self-motivated with the ability to work independently and proactively