Claims Quality Specialist

2 months ago

San Leandro, United States Community Health Center Network Full time

Organizational Description

The Community Health Center Network (CHCN), a sister organization to the Alameda Health Consortium, comprises eight federally qualified community health centers in Alameda County. CHCN functions as the managed care MSO for our health centers, contracting with the Alameda Alliance for Health and Anthem Blue Cross. To help our health centers fulfill their mission of providing the best possible care to their communities, we offer a broad range of training, technical assistance, quality improvement, information technology, and data analytic services.


Position Title: Claims Quality Specialist

Department: Claims

Reports To: Claims Manager

Classification: Non-Exempt

Status: Full-Time, Remote

Location: Candidate must be willing to have primary residence in California. For licensing and tax purposes, we are unable to hire candidates residing outside of the state of California starting on the date of hire.



POSITION SUMMARY

The Claims Quality Specialist is responsible for accurately processing all categories of specialty, ancillary, PCP, and ER/UC claims through reviews of internal, health plan, and state audits. The specialist also develops and provides claim examiner training based on audit findings.


ESSENTIAL POSITION RESULTS

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may perform other duties as assigned.


  • Monitor the accuracy of processed claims based on a comprehensive knowledge of benefit packages, utilization guidelines, and appropriate division of financial responsibility.
  • Lead all phases of the health plan claims audit process through completion.
  • Provide various health plan audit reports as needed.
  • Conduct internal focus audits on claim examiners.
  • Provide feedback to claims examiners individually or in a group setting based on audit findings.
  • Train team members in claim processing and workflow changes resulting from benefit updates and/or audit findings.
  • Analyze and identify quality trends and provide solutions.
  • Process check run reports and complete the check run process as assigned.
  • Perform EZCAP testing and monitoring on new plan benefits and system enhancements.
  • Research and resolve escalated claims inquiries and contact provider offices as needed.
  • Examine all types of claims based on a comprehensive knowledge of benefit packages, utilization guidelines, and appropriate division of financial responsibility.
  • Assist in improving workflows and updating policies and procedures for the department.
  • Perform other duties as assigned.


QUALIFICATIONS


Competencies:

  • Knowledge of PCP, specialty, ancillary, ER, and facility claims processing in an MSO/IPA setting.
  • Knowledge of CPT and ICD-10 coding.
  • Minimum of two to four years of demonstrated experience in an MSO/IPA setting.


Essential Requirements:

  • Organized self-starter with the ability to proactively problem-solve, manage outcomes on multiple projects, and meet deadlines.
  • Ability to communicate with team members, internal customers, and stakeholders openly with integrity and transparency.
  • Collaborative team player who works well with others and contributes positively to the team dynamic.
  • Excellent written and verbal communication skills, allowing for effective communication at any level.


PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.


WORKING CONDITIONS AND ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly exposed to an inside environment.


The Community Health Center Network is an Equal Opportunity Employer.

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