Under general supervision, provides claims specialized tasks relevant to an assigned program and/or project. This position requires analytical, administrative and specialized background or knowledge specific to the claims area and projects to which assigned. Individuals often work independently, exercising discretion and judgment and may coordinate or supervise a function and the work of others within the project or program they’re representing. Provides feedback to claims management to help prioritize improvement opportunities and monitor performance.
- Plan and facilitate continuous improvement activities and practices with a focus on the elimination of waste and rework, improving quality, reducing operational costs, improving efficiencies and standardizing processes/procedures.
- Work collaboratively with the Business Analyst and Training Coordinator to identify process improvement opportunities.
- Develop project plans for implementing improvements; monitor new process to ensure they achieve desired results.
- Monitor business needs. Create, develop, enhance and document processes and procedures.
- Monitor and communicate to claims management process deficiencies identified from provider disputes and error trend reports. Recommend solutions for improvement.
- Work in conjunction with the Claims Training Coordinator to help develop tools for training by collaborating with other departments within CalOptima.
- Identif y best practices to ensure compliance with regulatory guidelines.
- Analyze and summarize claims data to assist in accurate and timely processing of claims.
- Run reports by utilizing PDR and Q/A databases.
- Other projects and duties as assigned.
- Conduct research and make recommendations on findings with minimal assistance.
- Navigate the Internet as a resource for gathering information as it pertains to regulatory compliance.
- Run reports from an Access database.
- Prioritize workload based on business needs.
- Multi-task and work independently.
- Be well organized and detail-oriented.
- Communicate effectively, both verbally and in writing.
Experience & Education
- A combination of professional education in the area of Claims Administration, such as a relevant Bachelor’s degree, and/or equivalent experience that would provide the knowledge and abilities listed.
- Medical Terminology, CPT-4, HCPC coding and ICD-9. Both Medicare and Medi-Cal billing and claims adjudication experience required.
- Project management skills.
- Developing and presenting training materials.
- Experience using claims billing systems.
- DHCS, DMHC and CMS regulations.
- Claims managed care benefits and adjudication including both Medi-Cal and Medicare.
- Services, policies, and general responsibilities and requirements/regulations of programs.
- Practices and techniques required to function with other professionals working in an assigned program.
- Methods and techniques for organizing and implementing programs and projects.
- AB1455 and the appeals process.
- Health Insurance Portability and Accountability Act (HIPAA).
- Working knowledge of Excel, Word, Outlook Access and PowerPoint.