Claims Adjustment and Dispute Specialist

SAN JOAQUIN COUNTY HEALTH COMMISSION•French Camp, CA

1d•Remote

About The Position

Under general supervision, the Claims Adjustment and Dispute Specialist researches, resolves, and completes provider disputes, adjustment requests, and other assigned items. The role reviews provider disputes, researches payment history, submits MND requests to UM for review, applies payments or requests refunds according to established guidelines, and sends required correspondence. It also reviews call logs and resolves issues or reassigns them to the appropriate department; identifies, documents, and escalates claims error patterns and trends; researches and reprocesses assigned claims; and reviews corrected claims and adjustment requests for accuracy and processing. This is a remote position, and candidates must reside in California. Remote work is contingent on business needs and company guidelines. Employees working remotely are expected to maintain a secure, distraction-free workspace and reliable internet connectivity consistent with company standards. The position may involve occasional travel and occasional handling of materials up to 50 pounds. The work may require coping with a fast-paced environment, pressure, changing priorities and deadlines, frequent decision-making, irregular hours, and sensitive situations.

Requirements

High school diploma or general education degree.
At least one year at an analyst I level or equivalent.
Basic knowledge of regulations governing Medi-Cal as they relate to claims processing.
Basic knowledge of procedure coding and medical terminology and their application in claims.
In-depth knowledge of general medical policy benefits and exclusions.
In-depth knowledge of industry-standard payment practices.
In-depth knowledge of HPSJ systems as they relate to claims processing.
Ability to produce accurate, complete work and an appropriate amount of work.
Ability to learn through experimentation and to recover from setbacks and adversity.
Ability to identify efficient processes and focus on continuous improvement.
Effective interpersonal skills and ability to interact with diverse groups.
Strong oral and written communication skills, including professional expression, appropriate grammar and spelling, and documentation according to standards.
Ability to work independently and as part of a team.
Commitment to HPSJ’s strategy, vision, mission, and values.
Basic problem-solving and analytical skills, including routine analysis using identified data and information.
Time-management and organizational skills, including meeting deadlines and prioritizing work.
Basic arithmetic skills.
Basic skills in Windows, Excel, Word, and Outlook.
Ability to handle confidential information with appropriate discretion.
Ability to speak and be understood in English.
Must reside in California.
Must have legal and valid work authorization, a Green Card, or U.S. citizenship; the Health Plan does not sponsor visas.

Nice To Haves

Basic knowledge of claims adjustment processes.
QNEX experience.
Associate’s degree.
Claims adjustment experience.
Certification in medical coding or auditing.

Responsibilities

Research, resolve, and complete provider disputes, adjustment requests, and other assigned items.
Review provider disputes, research payment history, and submit MND requests to UM for review.
Apply payments or request refunds in accordance with established guidelines.
Send required correspondence.
Review call logs and resolve issues or reassign them to the appropriate department.
Identify claims error patterns and trends, document findings, and escalate them.
Review, research, and reprocess assigned claims.
Review corrected claims and adjustment requests for accuracy and process them.

Benefits

Medical coverage with HMO and PPO plan options.
Employee Wellness Program promoting physical, mental, and financial well-being.
Dental and vision plans with multiple provider choices.
Paid time off accruing up to three weeks, four paid floating holidays, and nine paid holidays.
CalPERS retirement pension program, automatic employer-paid retirement contributions, and a voluntary defined contribution plan.
Two flexible spending accounts for healthcare and dependent care expenses.
Employer-paid term life and AD&D insurance.
Employer-paid disability insurance.
Employer-paid Employee Assistance Program.
Health Advocacy to help employees navigate medical care and benefits.
Voluntary supplemental benefits, including medical, legal, and identity theft protection.
Online discount mall.
Tuition reimbursement.
Opportunity to work for a mission-driven organization focused on its members and community.