Provider Reconciliation Officer

Role Purpose

The Provider Reconciliation Officer is responsible for ensuring accurate reconciliation of healthcare providers' accounts by validating claims, invoices, payments, recoveries, credit notes, and provider statements. The role plays a critical part in maintaining financial accuracy, supporting timely provider settlements, minimizing disputes, and fostering positive provider relationships.

Within a Third-Party Administration (TPA) environment, the incumbent serves as a key liaison between healthcare providers, claims teams, medical teams, finance teams, and clients to ensure that provider accounts accurately reflect services rendered, approved claims, payments made, and outstanding balances. The role requires strong analytical skills, attention to detail, and a thorough understanding of healthcare claims processing and provider payment cycles.

Key Accountabilities

Provider Account Reconciliation

Perform regular reconciliation of provider statements against adjudicated claims and payment records.
Verify the accuracy of provider invoices, statements, remittances, and account balances.
Match approved claims against payments made to healthcare providers.
Review provider accounts to identify discrepancies, overpayments, underpayments, duplicate payments, and unallocated transactions.
Investigate and resolve unidentified or unmatched transactions.
Maintain accurate reconciliation schedules and supporting documentation.

Claims and Payment Verification

Validate claims included in provider invoices prior to payment processing.
Reconcile approved claims against contractual payment schedules and approved tariffs.
Verify deductions, recoveries, reversals, and adjustments applied to provider accounts.
Review rejected and partially settled claims and ensure proper documentation.
Ensure all payment records are accurately reflected in reconciliation reports.
Collaborate with Claims and Finance teams to address payment variances.

Provider Query and Dispute Resolution

Respond promptly to provider enquiries relating to invoices, payments, deductions, recoveries, and account balances.
Investigate provider disputes and reconciliation exceptions.
Liaise with relevant internal departments to obtain supporting documentation and resolutions.
Maintain records of provider disputes and resolution actions.
Follow up on open reconciliation issues until closure.
Ensure timely communication with providers regarding outstanding matters.

Financial Control and Risk Management

Identify financial discrepancies and escalate material risks appropriately.
Monitor ageing balances and unresolved reconciliation items.
Support recovery of overpayments and identification of duplicate claims.
Ensure compliance with reconciliation controls and financial procedures.
Assist in prevention and detection of billing irregularities and fraudulent claims.
Contribute to initiatives aimed at improving payment accuracy and financial controls.

Provider Relationship Management

Maintain professional working relationships with healthcare providers.
Participate in provider engagement meetings where reconciliation issues are discussed.
Support initiatives aimed at improving provider satisfaction and payment transparency.
Promote effective communication between providers and internal stakeholders.
Facilitate resolution of provider concerns through collaborative engagement.

Reporting and Documentation

Prepare daily, weekly, and monthly reconciliation reports.
Generate exception reports highlighting unresolved discrepancies.
Maintain comprehensive reconciliation records and supporting documentation.
Monitor reconciliation trends and recurring issues.
Provide reconciliation updates to management as required.
Support month-end and year-end financial reporting processes.

Process Improvement

Identify gaps and inefficiencies within reconciliation processes.
Recommend improvements to enhance reconciliation accuracy and efficiency.
Participate in process improvement projects and system enhancement initiatives.
Support implementation of new controls, procedures, and reconciliation tools.
Contribute to continuous improvement of provider settlement processes.

Compliance and Governance

Ensure compliance with organizational policies and procedures.
Adhere to contractual agreements with healthcare providers.
Maintain confidentiality of provider, client, and member information.
Support audit exercises by providing reconciliation documentation and reports.
Ensure compliance with regulatory and industry requirements.
Promote adherence to ethical and professional standards.

Key Performance Indicators

Provider Reconciliation Accuracy
Timeliness of Reconciliation Completion
Provider Query Resolution
Outstanding Reconciliation Item Resolution
Claims and Payment Matching Accuracy
Provider Dispute Resolution
Compliance with Reconciliation Procedures
Accuracy and Timeliness of Reconciliation Reports

Qualifications

Bachelor's Degree in Accounting, Finance, Business Administration, Economics, Insurance, Health Records, Healthcare Management, or a related field.
Proficiency in Microsoft Excel and reconciliation systems.

Experience

Minimum of 2 years' experience in healthcare finance, claims management, provider reconciliation, medical insurance, managed care, or a related field.
Experience working within a TPA, health insurer, managed care organization, or healthcare administration environment is preferred.

Core Competencies

Financial and Analytical Skills: Ability to analyze financial records, claims data, invoices, and reconciliation reports with a high degree of accuracy.
Attention to Detail: Ability to identify discrepancies, inconsistencies, and exceptions while maintaining high levels of accuracy.
Problem-Solving Skills: Ability to investigate reconciliation issues, identify root causes, and recommend effective solutions.
Stakeholder Management: Ability to effectively engage providers and internal teams to facilitate issue resolution and service delivery.
Communication Skills: Strong verbal and written communication skills with the ability to explain reconciliation findings and account variances.
Professionalism and Integrity: Demonstrates accountability, confidentiality, ethical conduct, and adherence to financial controls.