The Data Entry Tech is responsible for the accurate and timely review of the claims data file, as well as following regulatory and internal guidelines in conjunction with CalOptima policies and procedures as they apply to claims receipt and adjudication. The Data Entry Tech is also responsible for accurate data entry of claim forms, auditing and validating the accuracy of the claims data lift from the scanning vendor, generate and review daily claims reports. This position has analytical, and/or administrative responsibilities specific to the functional area to which assigned.
- Responsible for accurate and timely review of claim form data according to guidelines.
- Ensuring accuracy and validity of all claims data.
- Reconcile daily scanned claim volume report from vendor, report any discrepancy to supervisor.
- Determine the completeness of claim forms in order to determine if claim meets regulatory processing guidelines.
- Review and research claims for correct provider and member eligibility.
- Create a review daily claims reports, update claims data in the claims adjudicating system.
- Update claims information in a shared database between Claims Department and Provider Enrollment Team of providers that are not actively registered with CalOptima.
- Handle claims mail and triage to appropriate persons.
- Alert supervisor of any issues that impact production and quality.
- Validate claims based on claim department workflows.
- Monitor claims based on compliance regulation and timeframes.
- Manual data entry of claims with appropriate information as required.
- Maintain quality and productivity standards as set by management.
- Review the rejected claim file received from vendor to determine appropriate course of action.
- Assist Supervisor in monitoring claim turnaround time (TAT).
- Responsible for sending misrouted claims to the appropriate group within 10 (ten) business days.
- Update and prepare reports for management team as assigned.
- Ensure all Protected Healthcare Information (PHI) is locked at the end of the day.
- Other duties as assigned by management.
- Use 10-key by touch.
- Data entry with high accuracy rate (98%).
- Analyze files and determine appropriate course of action.
- Work independently and as part of a team.
- Develop and maintain effective working relationships with all levels of staff.
- Maintain organized files and be detail oriented.
- Communicate effectively.
- Effectively utilize computer and appropriate software and interact as needed with CalOptima Claims Processing Systems.
Experience & Education
- High School graduate or equivalent.
- 1-3 years of data entry experience.
- Medical claims experience preferred.
- Different types of Medi-Cal Claim Forms; CMS1500, UB04, PM160, 25-1.
- Standard Medical Terminology, CPT-4, HCPC, Revenue Codes, and ICD-9 preferred.
- MS Office: Outlook, Excel, Access, and Word.