Claims Specialist

Overview

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

Responsibilities

•  ESSENTIAL DUTIES AND 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 departmentguidelines 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 possibleeffective procedure changes.- Records daily production statistics and related activities on appropriate reports; turns alllogs and reports into the Claims Supervisor.- Other duties as assigned.

 

Qualifications

 

 

Education and Experience

 

 

Minimum three (3) years claims examining experience; or Partnership claimsexamining experience and completion of Partnership claims training; orequivalent combination of education and experience; College coursework 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 diagnosticcoding. Knowledge of Partnership Claim Policy and Procedures, EDS providermanual guidelines, Title 22 regulations and any other required policies,procedures, regulations, and manuals. Typing speed 30 wpm andproficient use of 10-key calculator. Valid California driver’s license andproof of current automobile insurance compliant with Partnership policy arerequired to operate a vehicle and travel for company business.

 

 

Performance Based Competencies

 

 

Excellent oral and written communication skills. Ability to effectivelyexercise good judgment within scope of authority and handle sensitiveissues with tact and diplomacy. Ability to work on multiple tasks withinestablished time frames and sometimes with conflicting priorities. Goodorganizational skills with ability to maintain accurate records anddocumentation of actions and decisions.

 

 

Work Environment And Physical Demands

Ability to use a computer keyboard; more than 80% of work time is spentin front of a computer monitor. When required, ability to move, carry, orlift objects of varying sizes, weighing up to 25 lbs. Ability to attend offsite 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:

 

$36.00 - $45.01

 

 

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.