Claims Processor I

2 weeks ago

Alameda, United States ALAMEDA ALLIANCE FOR HEALTH Full time

**PRINCIPAL RESPONSIBILITIES**:
Under the direct supervision of a Claims Processing Supervisor and the general direction of the Manager, Claims Production, this position is primarily responsible for the accurate review, entry and processing of claims received for payment by Alameda Alliance for Health (AAH).

Principal responsibilities include:

- Research claims for completion and appropriateness.
- Review and handle rejected claims as necessary.
- Evaluate HealthSuite error screen and base payment determination using AAH claims processing guidelines.
- Utilize Claims Department policies & procedures, workflows and manuals to meet Departmental production and quality metrics.
- Meet or exceed established individual production standards and collaborate with other Claims staff to ensure departmental compliance targets are met. The current production standard for this position is a minimum average of 20 claims per hour.
- Meet or exceed a financial and procedural accuracy standard of 97%.
- Review routine claims and edits to determine the appropriate handling for each including paying, denying or suspending for Claims Processor I or Supervisor review.
- Communicate identified issues with claims and claims processes to Supervisor or Manager.
- Actively participate and collaborate with entire department to continuously improve workflows and performance.
- Perform other duties and special projects as assigned.

**ESSENTIAL FUNCTIONS OF THE JOB**
- Process claims of a routine type using claims processing system.
- Review and analyze claims for routing to appropriate departments for resolution.
- Routinely meet Departmental performance and quality metrics.
- Comply with AAH’s Code of Conduct, and all regulatory requirements.

**PHYSICAL REQUIREMENTS**
- Constant and close visual work at desk or computer.
- Constant sitting and working at desk.
- Constant data entry using keyboard and/or mouse.
- Constant 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.

**Number of Employees Supervised: 0**

**MINIMUM QUALIFICATIONS**:
**EDUCATION OR TRAINING EQUIVALENT TO**:

- High School Diploma or equivalent is required.

**SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE)**:

- Knowledge of medical billing and/or medical terminology required.
- Knowledge of Medi-Cal or Medicaid programs required.
- Ability to work in cooperation with others.
- Ability to communicate effectively, both verbally and in writing.
- Ability to handle multiple projects simultaneously and balance priorities.
- Experience in the use of Microsoft Office software (Outlook, Word, Excel).

**SALARY RANGE $26.07-$39.10 Hourly**

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.

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