Lead Claims Specialist

Partnership HealthPlan of California•Fairfield, CA

11d•$37 - $47

About The Position

To support the Claims Department in maintaining pended claims, corrected claim inquiries and claims adjustment projects within established guidelines. Reviews and processes complex claims, supports claims examining, while offering additional training or support to the Claims Specialist Team.

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 judgement within score of authority and handle sensitive issues with tact and diplomacy.
Ability to work on multiple tasks within established time frames and sometimes with competing priorities.
Good organization 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.

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
Cross trained and functional in all Partnership claim types
Complete audits of the Specialist staff as requested
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
Answers questions of the Specialist Staff in a timely and efficient manner utilizing eROUTES
Monitor and report CIF Inventory weekly
Review aging CIFS and research reasons for aging; communicate any CIFS over 10 days this with the CSR Manager
Prepare meeting agendas for Specialist Meetings as requested
Maintain established guidelines of claims production and quality
Other duties as assigned.