Claims Specialist

Claims Examiner

To support the Claims Department in maintaining pended claims and claim adjustments within established guidelines. Reviews and processes complex claims, and supports claims examining.

Responsibilities

• Researches and processes claim adjustment requests.
• Participates in special claim adjustment projects as assigned.
• Assists in maintaining pended claim reports and files within established department guidelines and program policies.
• Performs claims examining functions as assigned.
• Performs claims customer service functions as assigned.
• Assists in training claims staff as needed.
• Monitors efficiency of operations and provides feedback to management on possible effective procedure changes.
• Records daily production statistics and related activities on appropriate reports; turns all logs and reports into the Claims Supervisor.
• Other duties as assigned.

Qualifications

Education and Experience

Minimum 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 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, 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 Competencies

Excellent oral and written communication skills. Ability to effectively exercise good judgment within scope of authority and handle sensitive issues with tact and diplomacy. Ability to work on multiple tasks within established time frames and sometimes with conflicting priorities. Good organizational skills with ability to maintain accurate records and documentation of actions and decisions.

Work Environment And Physical Demands

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

HIRING RANGE:

$ 28.63 - $ 37.22

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.