Claims Quality Specialist
2 months ago
The Community Health Center Network (CHCN), sister organization to the Alameda Health Consortium, is made up of the 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. In order to help our health centers meet their missions of providing the best possible care to their communities, we also provide 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
POSITION SUMMARY
The Claims Quality Specialist will be responsible for the accurate processing of all categories of specialty, ancillary, PCP and ER/UC claims through review and daily audit. Develops and provides examination training based on findings from audit process.
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.
- Responsible for monitoring the accuracy of processed claims based on a comprehensive knowledge of benefit package, utilization guidelines and appropriate division of financial responsibility.
- Participate in Claims Department team to improve workflow processes and documentation.
- Provide feedback to claims examiners individually or in group setting based on audit findings.
- Examination of all types of claims based on a comprehensive knowledge of benefit package, utilization guidelines and appropriate division of financial responsibility
- Lead all phases of health plan claims audit process through completion
- Provide various Health Plan audit reports as needed.
- Perform EZCAP testing on new plan benefits and system enhancements
- Contact provider office for additional information to help with claims processing as needed
- Process check run report and complete process as assigned
- Analyze and identify quality trends and provide solutions.
- Conduct Focus audits for providers and examiners
- Training on claim processing and workflow as needed
- Participate in updating Policy & Procedures for Claims Department
- Assist with customer care inquires
- Perform other duties as deemed appropriate
HIPAA Designated Access
“For the purposes of the job duties of this position, the person in this position requires access only to the following HIPAA protected information data sets”
1. MSO Membership
2. MSO Claims
3. MSO Referral/Auth.
4. MSO Capitation
5. Data Warehouse
6. Chart Audit/QI
7. Disease Registry
SUPERVISORY RESPONSIBILITIES
None
MINIMUM QUALIFICATIONS
Competencies
- Comprehensive knowledge of PCP, Specialty, Ancillary, ER and Facility claims processing in an IPA/HMO setting.
- Excellent written and verbal communication skills, to allow for effective communication at any level.
- Proficient in CPT and ICD-10 coding.
- Organized and self-directed person with the desire to learn and the ability to work well with others.
- Ability to prioritize and manage multiple projects and maintain deadlines.
Essential Requirements
- Minimum of two to four years demonstrated experience in medical claims processing as a level II or higher.
CERTIFICATES AND/OR LICENSES
- High school diploma or General Education Degree (GED) required
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/outside environment.
The Community Health Center Network is an Equal Opportunity Employer.
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