Claims Resolution Coordinator

Partnership HealthPlan of California•Santa Rosa, CA

20d•$37 - $47

About The Position

To research and resolve complex claims issues which cross interdepartmental lines and communicate the outcome to providers and affected Partnership managers. Develops and maintains provider training materials for all lines of business. Conducts provider trainings across Partnership departmental lines in group or individual provider settings.

Requirements

Minimum four (4) years claims examining experience; three (3) years Partnership CSR III or above claims experience and completion of Partnership claims training; or equivalent combination of education and experience; College course work in business or related field preferred.
Familiarity with Medi-Cal and/or managed care claims processing.
Knowledge of CPT, HCPC procedure coding, and ICD-9 diagnostic coding.
Knowledge of Partnership Claim Policy and Procedures, Medi-Cal provider manual guidelines, Title 22 regulations and any other required policies, procedures, regulations, and manuals.
Typing speed 30 wpm and proficient use of 10-key calculator.
Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.
Ability to analyze and research claims issues.
Excellent written and oral communication skills.
Ability to present statistical and technical data in a clear and understandable manner.
Good organization skills.
Ability to work on multiple assignments simultaneously, prioritize work and complete projects within established time frames.
Use good judgment in making decisions within scope of authority and handle sensitive issues with tact and diplomacy.
Ability to use a computer keyboard.
More than 70% of work time is spent in front of a computer monitor.
Ability to lift 25lbs.
Periodic travel and overnight stays may be required.

Nice To Haves

College course work in business or related field preferred.

Responsibilities

Answers customer service lines as necessary and responds to provider inquiries either by phone, email, or in person regarding claims related questions.
Reviews, researches, and works with various departments to resolve complex provider inquiries, appeals, and grievances.
Acts as a resource and provides support to customer service staff, as well as Provider Relations staff for complex Provider questions regarding claims and payments.
Coordinates with Claims, Member Services, Health Services departments, the development, maintenance, and training of ongoing educational materials and tips for inclusion on the Partnership website. Incorporates educational materials into the PR Manual and update on a quarterly basis.
Processes CIF's and adjustments as needed.
Writes and runs reports in Business Objects to obtain needed claim data.
Tracks and analyzes provider trends with denials and CIF's to provide support to providers with an opportunity to improve. Distributes provider scorecards.
Tracks complaints, appeals, and grievances by program. Reports activities on a quarterly basis to IQI, Partnership Compliance Coordinator, and Claims Director.
Presents findings and recommendations for ongoing, long term resolutions to issues. Identifies items to address the “provider hassle factor.”
Acts as liaison and meets with designated staff from Claims, Health Services, Member Services, and QI departments to identify ongoing provider issues.
Coordinates system issues with Claims Configuration staff, IT staff, and PR Lead Project Specialist/Auditor. Leads or participates in special projects as needed.
Other duties as assigned