Under the general supervision of the Supervisor, Claims Support Services, the principal responsibility of the Claims Specialist – Provider Services will be to support the Provider Services phone and field representatives by analyzing and resolving claims issues from providers. This includes analyzing provider billing practices, Alliance claims processing decisions, prior authorization requirements adherence, potential system configuration issues, and contractual terms to assess accuracy of claims processed. The Claims Specialist – Provider Services will adjust claims, as appropriate, or work with the Supervisor to have the claims corrected. As time permits, the position will also perform the other functions of the Claims Specialist which includes:
· Audit Activities – Audit a designated percentage of all daily processing production for assigned staff members; Conduct periodic focused claims for specific claim types; Conduct weekly high dollar audits
· Recovery Activities – Initiate recovery activities resulting from claim audits, Service Requests, provider requests or other sources; analyze errors to determine their root cause and identify additional recovery opportunities related to the root cause.
· Research and Resolution Activities – Review, research and resolve various claims projects resulting from provider identified issues or as the result of system configuration changes; Review, research, and resolve complex claims processing issues, including Service Requests, Provider Disputes, member billing issues and adjustment projects.
· System Testing Activities – Perform system testing for new software implementation and/or system upgrades; Perform testing on routine system configuration changes including new provider contracts, provider contract amendments, fee schedule changes and new benefit or program changes.
· Miscellaneous Activities – Review, research and apply claim edits from claims processing systems; Perform other duties and special projects as specified by the Director, Claims and/or Supervisor, Claims Support Services.
ESSENTIAL FUNCTIONS OF THE JOB
· Research provider claim issues; adjust claims as necessary.
· Audit, research and maintain the record of audit results.
· Assist with audits of internal or delegated claims processing.
· Initiate and pursue recovery opportunities.
· Assist in testing of new software implementation and/or system upgrades.
· Analysis of claims data and application of claim policy.
· Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
· Constant and close visual work at desk or computer.
· Constant data entry using keyboard and/or mouse.
· Constant sitting and working at desk.
· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
· Frequent lifting of folders and other objects weighing between 0 and 20 lbs.
· Frequent walking and standing.
EDUCATION OR TRAINING EQUIVALENT TO:
· High School Diploma or equivalent is required.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Five or more years in a managed care claims processing environment required, including the processing of all medical claim types and the handling of complicated claims issues.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Knowledge of organizational and departmental operations, reimbursement and legal/regulatory guidelines.
· Understanding of state and CMS regulatory requirements.
· Strong claims processing auditing experience.
· Must have detailed knowledge of CPT, HCPCS, RVS, ICD-10, CMS1500/UB04 coding and forms.
· Ability to correctly interpret claims processing rules, regulations, and procedures.
· Ability to plan and execute projects independently.
· Ability to communicate effectively, both verbally and in writing.
· Ability to handle multiple projects and balance priorities as well as work for a number of individuals.
· Excellent writing and editing skills and ability to summarize complex information clearly and accurately.
· Well organized and detail oriented.
· Knowledge of Medi-Cal guidelines and processing.
· Excellent critical/analytical thinking and problem solving skills.
· Proficient experience in Microsoft Office products.
· Knowledge of and experience with HealthSuite preferred.
$28.25 - $42.37