California Children Services Specialist

COMMUNITY HEALTH GROUP•Chula Vista, CA

5d•$21 - $24•Onsite

About The Position

The California Children Services Specialist assists with coordinating care with the local CCS program to identify and refer children with CCS-eligible conditions. The role works with relevant departments to ensure processes, programs, and services are completed efficiently and on time in accordance with company policies and procedures and applicable state and federal regulations, including CMS and/or Medicare Part D and Special Needs Plan requirements. The specialist supports identification and referral of CCS-eligible members, submits and follows up on applications, researches denials and potential appeals, maintains CCS-related records and systems, and coordinates with staff, case managers, providers, pharmacies, and local CCS personnel. The position also reviews claims and drug utilization information to identify potential CCS-related cases and helps ensure compliance with CCS program requirements. This is a full-time position based at the corporate headquarters in Chula Vista, California. The stated salary range is $21.40–$23.54 per hour.

Requirements

High school graduate.
Medical terminology and/or coding certificate required.
Experience in a health care setting.
Knowledge of Microsoft programs, including word processing, spreadsheets, and databases.
Familiarity with CPT, ICD-9, HCPCS, and Medi-Cal coding.
Ability to communicate effectively verbally and in writing.
Skill in data gathering and analysis and working in cross-functional teams.
Ability to organize work effectively and determine priorities.
Ability to perform prolonged periods of sitting at a desk and working at a computer terminal, with intermittent standing, walking, bending, stooping, and lifting 10 pounds or less.
May be necessary to work and attend meetings outside the facility or normal business hours.

Nice To Haves

Familiarity with CCS, Medi-Cal, and other government programs.
Experience with the CCS Program or similar government programs.

Responsibilities

Use current CCS guidelines and established policies and procedures to improve identification of members who are medically eligible for the CCS program.
Develop reports to identify possible cases or diagnoses and work with department staff to maximize identification of potential CCS-eligible cases.
Submit applications to the CCS program within five business days of case identification and ensure applications are complete and not returned or rejected as incomplete.
Review cases pending CHG determination based on medical documentation submitted to CCS, and work with staff and providers to obtain completed applications or missing information.
Research CCS denials for possible appeals and coordinate with local CCS staff to ensure potential CCS reviews are completed accurately and on time.
Improve and restructure CHG's system for documenting CCS in coordination with the CCS online system, and assist with overall care coordination for CCS-eligible children.
Maintain the CHG MIS system with current CCS determinations based on research of the CCS online system.
Document and communicate care coordination for CCS-eligible children by reviewing claims for potentially CCS-eligible services, monitoring cases pending CCS determination, updating CHG systems when decisions are completed, and obtaining necessary medical information from staff, case managers, and providers.
Help develop processes for documenting overall coordination of care for CCS-eligible children.
Improve identification of pharmaceutical use linked to CCS-eligible conditions by reviewing drug utilization reports and drug profiles, identifying relevant member and medication combinations, and identifying medications carved out for CHG payment.
Work with the Pharmacy Services Coordinator to educate the pharmacy network about CCS policies and procedures, and work with Member Services staff to redirect members to CCS pharmacy providers.
Maintain current knowledge of CCS program policies, procedures, and guidelines, and work with key staff to support compliance and identify opportunities for improvement.
Convey a professional image, contribute to team efforts, participate in committees and meetings, and perform other duties as assigned or requested.