Claims Specialist

Partnership HealthPlan of California • Fairfield, CA

56d • $35 - $43

About The Position

To support the Claims Department in maintaining pended claims and claim adjustments within established guidelines. Reviews and processes complex claims, and supports claims examining.

Requirements

• Minimum three (3) years claims examining experience; or Partnership claims examining 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, EDS 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.
• Excellent oral and written communication skills.
• Ability to effectively exercise good judgment within scope of authority and handle sensitive issues with tact and diplomacy.
• Ability to work on multiple tasks within established time frames and sometimes with conflicting priorities.
• Good organizational skills with ability to maintain accurate records and documentation of actions and decisions.
• Ability to use a computer keyboard; more than 80% of work time is spent in front of a computer monitor.
• When required, ability to move, carry, or lift objects of varying sizes, weighing up to 25 lbs.
• Ability to attend off-site meetings as required.
• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

Nice To Haves

• College course work in business or related field preferred.

Responsibilities

• Researches and processes claim adjustment requests.
• Participates in special claim adjustment projects as assigned.
• Assists in maintaining pended claim reports and files within established department guidelines and program policies.
• Performs claims examining functions as assigned.
• Performs claims customer service functions as assigned.
• Assists in training claims staff as needed.
• Monitors efficiency of operations and provides feedback to management on possible effective procedure changes.
• Records daily production statistics and related activities on appropriate reports; turns all logs and reports into the Claims Supervisor.
• Other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed
• Number of Employees: 501-1,000 employees