Claims Operations Senior Specialist

KHS•Bakersfield, CA

1d•$36 - $46•Hybrid

About The Position

This highly specialized position is responsible for analyzing statistics of all areas of Claims daily; and assisting in priority area as needed. This position is responsible for knowing and performing all functions within the department: Claims Processing, Auditing, Disputes/Rework, Calls, Training, Inventory Control, Systems Testing, Overpayments, and Encounter Processing – and offering suggestions for improvements to Management. This position is also responsible for keeping abreast of Medi-Cal, Commercial and Medicare rules for Dual membership or other LOB (Dental, Vision, LTC, Transplants, Mental Health, Pharmacy, etc.) and training when necessary. This position is responsible for identifying area most in need of attention and applying their knowledge and skill to help that specific area to be within operating standards/goals. This position will be required to perform all functions within Claims Operations. This position will use experience to identify areas to improve in workflow, system enhancements, and Auto Adjudication. This position will also be the primary SME for all other Lines of Business from Medicare to Commercial or other new benefits for Medi-Cal.

Requirements

Bachelor’s degree in business from an accredited university or equivalent required AND ten (10) years of direct experience in combination of a minimum of eight (8) functions: Claims Processing, Auditing, Provider Dispute Processing/Rework, Claim Call Representative, Training, Inventory Control, System Testing, Overpayment Recovery, and/or Encounter Processing. Experience in Medicare, Medi-Cal and Commercial lines of business required.
-OR-
Fourteen (14) years of direct experience in combination of a minimum of eight (8) functions: Claims Processing, Auditing, Provider Dispute Processing/Rework, Claim Call Representative, Training, Inventory Control, System Testing, Overpayment Recovery, and/or Encounter Processing. Experience in Medicare, Medi-Cal and Commercial lines of business required

Responsibilities

Analyze and identify (on a daily basis) area in Claims Department needing most assistance to hit optimal benchmarks.
Perform Claims Processing at all levels, Auditing, Dispute Processing, Calls, Overpayments, Encounter Processing, Training, Inventory Control and System Testing at optimum levels as needed with flexibility day to day.
Analyze via reports and experience in daily handling of all related department duties and recommend changes to work processes as needed.
Analyze via reports and experience in daily handling of all related department duties and recommend system enhancements/Auto Adjudication as needed.
Write and run reports in Business Objects as needed.
Acts as a resource and provides support to Customer Service and Provider Relations regarding Claims Payments.
Track and trend Provider disputes, denials and calls to effect improvement in compliance with billing rules and/or opportunities for Provider Training.
Key contact and oversight of Supplemental Payment programs via the Claims Department (Prop 56, GEMT, etc.).
Liaison with High Dollar Claim Review Vendor – monitor, verify, and validate data as well as communicate needs to vendor.
Performs other job-related duties as required.
Adheres to all company policies and procedures relative to employment and job responsibilities.
Telecommuting jobs will require some on site meetings/ trainings as identified by management.