Claims Specialist

Partnership HealthPlan of California•Fairfield, CA

10d•$36 - $45

About The Position

The Claims Specialist supports the Claims Department by maintaining pended claims and claim adjustments within established guidelines. The role reviews and processes complex claims, assists with claims examining, and supports customer service, staff training, operational monitoring, and departmental reporting. Employees are also expected to provide a high level of service, promote teamwork, maintain safe practices, and follow HealthPlan policies and procedures.

Requirements

At least three years of claims examining experience; or Partnership claims examining experience and completion of Partnership claims training; or an equivalent combination of education and experience.
Familiarity with Medi-Cal and/or managed care claims processing.
Knowledge of CPT and HCPC procedure coding and ICD-9 diagnostic coding.
Knowledge of Partnership Claim Policy and Procedures, EDS provider manual guidelines, Title 22 regulations, and other required policies, procedures, regulations, and manuals.
Typing speed of 30 words per minute.
Proficient use of a 10-key calculator.
Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy, required to operate a vehicle and travel for company business.
Excellent oral and written communication skills.
Ability to exercise good judgment within the scope of authority and handle sensitive issues with tact and diplomacy.
Ability to work on multiple tasks within established time frames, including when priorities conflict.
Good organizational skills and ability to maintain accurate records and documentation of actions and decisions.
Ability to use a computer keyboard.

Nice To Haves

College coursework in business or a related field.

Responsibilities

Research and process claim adjustment requests.
Participate in special claim adjustment projects as assigned.
Help maintain pended claim reports and files in accordance with department guidelines and program policies.
Perform claims examining functions as assigned.
Perform claims customer service functions as assigned.
Assist with training claims staff as needed.
Monitor operational efficiency and provide management with feedback on possible procedure changes.
Record daily production statistics and related activities on appropriate reports, and submit logs and reports to the Claims Supervisor.
Perform other duties as assigned.
Provide the highest possible level of service to clients.
Promote teamwork and cooperative effort among employees.
Maintain safe practices and abide by HealthPlan policies and procedures.