Claims Processor Ii
2 months ago
[H.S. Diploma or Equivalent
**Hours**:
**Shift Start Time**:
7:30 AM
**Shift End Time**:
4:30 PM
**AWS Hours Requirement**:
8/40 - 8 Hour Shift
**Additional Shift Information**:
**Weekend Requirements**:
As Needed
**On-Call Required**:
No
**Hourly Pay Range (Minimum - Midpoint - Maximum)**:
$23.750 - $29.477 - $35.204
**What You Will Do**
This position will be responsible for processing specialty and ancillary service claims, specific to contract agreements and Health Plan Division of Financial Responsibility's (DOFR's). Duties also include verifying patient account, eligibility, benefits and authorization information; analyze the information to determine payment amount or denial of payment.
**Required Qualifications**
- 4 Years experience in Managed Care (HMO, Medicare, Covered California, Medi-Cal) with demonstrated performance that consistently exceeds expectations.
**Other Qualification Requirements**
- High School Diploma or equivalent; or 1 year of related Claims experience in lieu of High School Diploma - Required
**Essential Functions**
- Claims processing
Verifies patient account, eligibility, benefits and authorization information; analyze the information to determine payment amount or denial of payment.
Utilizes coding software to determine if procedure codes billed are unbundled or payable by the Correct Coding Initiative guidelines.
Researches and applies appropriate payment/denial guidelines for benefits, coordination of benefits, 'unclean' claims and member denials.
Identifies claims for edits based on contract and authorization specifics, DOFR's, newborn guidelines.
Reviews and processes 90-100 claims a day or 450-500 claims per week.
Makes appropriate edits and corrections to claims in the system to ensure accurate and timely payment of claims.
Generates member denial letters based on criteria given for claims that meet the financial responsibility of the member.
- Communication and teamwork
Consistently attends all scheduled meetings (departmental and interdepartmental) and contributes ideas and constructive additions to established workflow.
Provides customer service to inside and outside callers with claims inquires in a professional and courteous manner.
Conducts the necessary research and coordination with internal and external departments to ensure that all claims inquiries and pended claim issues are handled and resolved in accordance with AB1455 guidelines.
- Internal and external customer service
Provides prompt, accurate and excellent services to internal and external customers.
Develops solid professional working relationships with various internal departments and external customers as required.
- Participates in other duties as assigned
Participates in special projects and other duties as assigned. These may include, but are not limited to, work groups, proposals, audits and back-up support for other departments.
- Training
Provides provider training and assistance to staff to maximize knowledge, customer orientation, and quality improvement.
Demonstrates good judgement and acts within established policies and procedures.
Fosters an environment that promotes accountability and team work.
- Unit performance
Unit performance reports are completed within 5 days from end of the month, with action plan to correct any negative variance from unit performance standard.
Receives feedback on unit performance from key customer base and responds to all feedback in a professional and timely manner.
**Knowledge, Skills, and Abilities**
- Proven knowledge of CPT, HCPCS, ICD-9/ICD-10, DRG’s, RBRVS codes and medical terminology for both electronic and paper claims.
- Proven knowledge of processing Provider Dispute Resolutions.
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class
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