Claims Analyst II

Santaclara Family Health Plan • San Jose, CA

62d

About The Position

The Claims Analyst II analyzes, processes and adjusts routine and complex facility and professional claims for payment or denial to support the Claims Department operations in a manner that maintains compliance within the Medicare and Medi-Cal regulatory requirements and achieves Claims service-level objectives.

Requirements

• High School Diploma or GED. (R)
• Minimum two years of claims processing experience in a Health Plan Claims Department. (R)
• Prior experience with managed care plans, Medi-Cal and/or Medicare programs, and working with underserved populations. (R)
• Ability to analyze, process and adjust routine and complex assigned claims in an accurate and timely manner. (R)
• Understanding of professional and hospital reimbursement methodologies, including medical terminology, and working knowledge of CPT, HCPCS, ICD-10, and ICD 9 codes. (R)
• Understanding of the relationship between the health plans, IPAs, and DOFR. (R)
• Ability to consistently meet Quality and Productivity Key Performance Indicators by participating in and achieving the Claims Quality standards. (R)
• Ability to consistently meet Attendance Key Performance Indicator by being punctual and meeting the Claims standards in accordance with the team schedule. (R)
• Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel. (R)
• Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
• Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R)
• Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
• Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
• Ability to maintain confidentiality. (R)
• Ability to comply with SCFHP's policies and procedures. (R)
• Ability to perform the job safely with respect to others, to property, and to individual safety. (R)

Nice To Haves

• Working knowledge of QNXT claims processing software. (D)

Responsibilities

• Follow established Health Plan policies and procedures and use available resources such as provider contracts, Medicare and/or Medi-Cal guidelines and Member Evidence of Coverage (EOC) to analyze, process and adjust routine and complex assigned claims in an accurate and timely manner.
• Research, identify, resolve and respond to inquiries from internal Health Plan departments regarding outstanding claims-related issues.
• Assist Claims Supervisor and Manager with pre-check run reports.
• Maintain and organize all processes related to Third Party Liability (TPL) claims, including communication of relevant information to appropriate parties.
• Participate in system testing and communicate newly-identified and potential issues to the Claims Supervisor and Manager and provide recommendations for improvement.
• Process claims refund checks on a weekly basis to ensure accuracy/completeness of information and submit to the Finance Department in a timely manner.
• Attend and actively participate in daily, weekly, and monthly departmental meetings, training and coaching sessions.
• Perform other related duties as required or assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Executive, Legislative, and Other General Government Support
• Education Level: High school or GED
• Number of Employees: 251-500 employees