Claims Resolution Coordinator

Overview

To research and resolve complex claims issues which cross interdepartmental lines and communicate the outcome to providers and affected Partnership managers. Develops and maintains provider training materials for all lines of business. Conducts provider trainings across Partnership departmental lines in group or individual provider settings.

Responsibilities

• Answer s customer service lines as necessary and r espond s to provider inquiries either by phone, email , or in person rega rding claims related questions.
• Review s , research es , and work s with various departments to resolve complex provider inqui ries, appeals, and grievances.
• Act s as a resource and provide s support to customer service staff, as well as Provider Relations staff for complex Provider questions regarding claims and payments.
• Coordinate s with Claims, Member Services, Health Services departments, the development, maintenance, and training of ongoi ng educational materials and tips for inclusion on the PHC website. I ncorporate s educational materials into the PR Manual and update on a quarterly basis.
• Process es CIF's and adjustments as needed.
• Write s and run s reports in Business Objects to obtain need ed claim data.
• Track s and analyze s provider trends with denials and CIF's to provide support to providers with an opportunity to improve. Distribute s provider scorecards .
• Track s complaints, appeals, and grievances by program. Report s activities on a quarterly basis to IQI, PHC Compliance Coordinator , and Claims Director.
• Present s findings and recommendations for ongoing, long term resolutions to issues. Identi fies items to address the “provider hassle factor.”
• Act s as liaison and meet s with designated staff from Claims, Health Services, Member Services, and QI departments to id entify ongoing provider issues.
• Coordinate s system issues with Claims Configuration staff, IT staff , and PR Lead Project Specialist/Auditor. Leads or participate s in special projects as needed.
• Other duties as assigned
  
  

Qualifications

Education and Experience

Minimum 1 year of experience in claims examining or customer service within healthcare, insurance, finance, or managed care environment; or equivalent combination of relevant experience and education.

Special Skills, Licenses and Certifications

Familiarity 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, Medi-Cal 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 Competencies

Ability to analyze and research claims issues. Excellent written and oral communication skills. Ability to present statistical a nd technical data in a clear and understandable manner. Good organization skills. Ability to work on multiple assignments simultaneously, prioritize work and complete projects within established time frames. Use good judgment in making decisions within sco pe of authority and handle sensitive issues with tact and diplomacy.

Work Environment And Physical Demands

Ability to use a computer keyboard. More than 60% of work time is spent in front of a computer monitor. When required, ability to move, carry or list objects of varying size, weighing up to 5 lbs.

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; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.
  
  

HIRING RANGE:

$ 37.22 - $ 46.53

IMPORTANT DISCLAIMER NOTICE

The 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.