Claims Processing Specialist I
2 weeks ago
Position Overview:
The role involves the examination, investigation, and resolution of claims pertaining to various Medi-Cal categories, adhering to defined productivity and quality benchmarks. This includes the generation of necessary documentation that accurately reflects the actions taken and the current status of each claim. The position also entails the creation of provider communications, such as letters, and the management of claims that require further review by other departments and personnel.
Key Responsibilities:
- Investigates, analyzes, and resolves pending claims for Medi-Cal categories, including medical, ancillary, long-term care, CHDP, encounter data, other coverage, and batch claims, while meeting established productivity and quality benchmarks. Completes claims from the Batch Error Report and Batch Pass Report.
- Directs claims to the relevant departments and internal personnel for additional examination. Ensures follow-up and completion of claims once responses are received.
- Adheres to established policies and procedures, including PHC Claims Operating Instruction Memorandums, State of California Medi-Cal Provider Manual guidelines, Title 22 regulations, and CMS guidelines when addressing pending claims.
- Produces claims correspondence as necessary.
- Records daily production metrics and related activities on appropriate documentation. 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 resolving all types of pending 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 combination of education and experience that is equivalent.
Special Skills, Licenses, and Certifications:
Proficient written and verbal communication skills. Strong organizational abilities.
Performance-Based Competencies:
Ability to exercise sound judgment within the scope of authority and manage sensitive issues with discretion. Capacity to maintain focus on repetitive tasks and achieve production and quality standards. Competence in completing tasks accurately within set timelines.
Work Environment and Physical Demands:
Proficiency in using a computer keyboard. Over 80% of work time is spent in front of a computer monitor. When necessary, the 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;
- Maintain 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 listed in this job description are representative only 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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