Job Title

To support the Claims Department in maintaining pended claims, corrected claim inquiries and claims adjustment projects within established guidelines. Reviews and processes complex claims, supports claims examining, while offering additional training or support to the Claims Specialist Team.Researches and processes claim adjustment requestsParticipates in special claim adjustment projects as assignedAssists in maintaining pended claim reports and files within established department guidelines and program policiesPerforms claims examining functionsCross trained and functional in all Partnership claim typesComplete audits of the Specialist staff as requestedPerforms claims customer service functions as assignedAssists in training claims staff as neededMonitors efficiency of operations and provides feedback to management on possible effective procedure changesRecords daily production statistics and related activities on appropriate reportsAnswers questions of the Specialist Staff in a timely and efficient manner utilizing eROUTESMonitor and report CIF Inventory weeklyReview aging CIFS and research reasons for aging; communicate any CIFS over 10 days this with the CSR ManagerPrepare meeting agendas for Specialist Meetings as requestedMaintain established guidelines of claims production and qualityOther duties as assigned.Education and ExperienceMinimum three (3) years claims examining experience; or Partnership claims examining experience and completion of Partnership claims training; or equivalent combination of education and experience; College course work in business or related field preferred.Special Skills, Licenses and CertificationsFamiliarity with Medi-Cal and/or managed care claims processing. Knowledge of CPT, HCPC procedure coding, and ICD-9 diagnostic coding. Knowledge of Partnership claim policy and procedures, EDS provider manual guidelines, Title 22 regulations and any other required policies, procedures, regulations, and manuals. Typing speed 30 wpm and proficient use of 10-key calculator. Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.Performance Based CompetenciesExcellent oral and written communication skills. Ability to effectively exercise good judgement within score of authority and handle sensitive issues with tact and diplomacy. Ability to work on multiple tasks within established time frames and sometimes with competing priorities. Good organization skills with ability to maintain accurate records and documentation of actions and decisions.Work Environment And Physical DemandsAbility to use a computer keyboard; more than 80% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying sizes, weighing up to 25 lbs. Ability to attend off-site meetings as required.All HealthPlan employees are expected to:Provide the highest possible level of service to clients;Promote teamwork and cooperative effort among employees;Maintain safe practices; andAbide by the Health Plan’s policies and procedures, as they may from time to time be updated.HIRING RANGE:$37.22 - $46.53IMPORTANT DISCLAIMER NOTICEThe job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions 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.