Claims Review Associate I

1 week ago

Fairfield, California, United States Partnership HealthPlan of California Full time

Position Overview:

The role involves the examination, investigation, and resolution of claims pertaining to various Medi-Cal categories while adhering to defined productivity and quality benchmarks. This includes the creation of necessary documentation that accurately represents the actions undertaken and the current status of each claim. Additionally, the position entails generating communications for providers, such as letters, and managing the routing and tracking of claims that necessitate further evaluation by other personnel and departments, processing them when feasible.

Key Responsibilities:

  • Investigates, reviews, and resolves outstanding claims for Medi-Cal categories including medical, ancillary, long-term care, CHDP, encounter data, other coverage, and batch claims, all while meeting established productivity and quality benchmarks. Completes claims identified in the Batch Error Report and Batch Pass Report.
  • Directs claims to the relevant PHC departments and internal personnel for further assessment. Ensures follow-up and completion of claims once responses to requests are received.
  • Adheres to established PHC policies and procedures, PHC Claims Operating Instruction Memorandums, State of California Medi-Cal Provider Manual guidelines, Title 22 regulations, and CMS guidelines when addressing outstanding claims.
  • Produces claims-related correspondence as necessary.
  • Maintains daily production statistics and associated activities on the appropriate reporting tools. Submits all logs and reports to the Medi-Cal Claims Supervisor.
  • Reviews all work audits promptly and submits any necessary adjustments and corrections within the designated timeframe.
  • Assists the Claims Department in addressing all types of outstanding claims.
  • Engages in special projects and assignments as required.
  • Performs other duties as assigned.

Qualifications:

Education and Experience:
A high school diploma or equivalent; prior experience in claims examination within an automated setting; or a comparable combination of education and experience.

Special Skills, Licenses, and Certifications:
Strong written and verbal communication skills. Excellent organizational abilities.

Performance-Based Competencies:
Ability to exercise sound judgment within the scope of authority and manage sensitive matters with discretion and diplomacy. Capacity to maintain focus on repetitive tasks and achieve production and quality standards. Proficiency in completing tasks accurately within established deadlines.

Work Environment and Physical Demands:
Ability to operate a computer keyboard. Over 80% of work time is spent in front of a computer monitor. When necessary, ability to move, carry, or lift objects of varying sizes, weighing up to 5 lbs.

Expectations for All HealthPlan Employees:

  • Deliver the highest possible level of service to clients;
  • Encourage teamwork and collaborative efforts among colleagues;
  • Uphold safe practices; and
  • Comply with HealthPlan policies and procedures, which may be updated periodically.

Compensation:
$25.00/hour

Disclaimer:
The duties, responsibilities, skills, functions, experience, educational factors, and requirements outlined in this job description are representative and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

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