Sr Claims Research Analyst - PFS Claims Processing - Sharp Corporate - Day Shift - Full Time

Sharp HealthCare•San Diego, CA

1d•Onsite

About The Position

Responsible for investigating and resolving complex health plan issues such as appeals, grievances, and claims resolution related to member and provider disputes. This role provides timely response to health plan issues, forwards claim issues to appropriate units for rework, and documents all actions. The analyst tracks and trends issues, making recommendations for improved contract set-up or claims adjudication policies. The position involves interaction with various internal and external departments, including Claims Dept, Contracts, Customer Service, Utilization Management, Appeals and Grievance Units of SRS, SCMG, SHP, and all health plan liaisons (Health Net, CIGNA, Anthem Blue Cross, Blue Shield, Aetna, United Health Care, Health Net Seniority, and Secure Horizons). The Analyst is expected to serve as a role model in overall conduct, knowledge, expertise, and compliance with policies, procedures, and safety regulations as defined by Sharp HealthCare.

Requirements

H.S. Diploma or Equivalent
15 Or More Years experience as a Claims Examiner in the insurance industry.
3 Years experience with supervisory responsibilities in a managed care environment, and demonstrated self-motivational abilities.
Excellent organizational and time management skills, ability to multitask.
Excellent analytical and problem-solving skills.
Proficient in medical terminology and use of ICD-9, CPT, HCPC coding systems.
Excellent verbal and written communication skills.
Ability to read, speak and hear English clearly.
Proficient in Excel, Word and Microsoft Office.
Ability to work independently in research and decision making with minimal direction from higher level staff.

Nice To Haves

Associate's Degree
Evidence of completion of Medical Terminology class.

Responsibilities

Investigating and resolving complex health plan issues such as appeals, grievances, and claims resolution related to member and provider disputes.
Providing timely response to the health plan issue.
Forwarding claim issue to appropriate unit for rework if necessary and documenting all actions in dedicated file on the common drive.
Tracking and trending issues and making recommendations for improved contract set-up or claims adjudications policies.
Interacting with various internal and external departments (Claims Dept; Contracts, Customer Service, Utilization Management, Appeals and Grievance Units of SRS,SCMG, SHP and all health plan liaisons (Health Net; CIGNA; Anthem Blue Cross, Blue Shield, Aetna, United Health Care, Health Net Seniority and Secure Horizons).
Serving as a role model in over all conduct, knowledge, expertise and compliance with policies, procedures and safety regulations as defined by Sharp HealthCare.
Distributes priority processing to appropriate unit.
Completes Error Tracking Log accurately and timely.
Confirms accurate and timely completion of distributed work.
Reports any issues to management and originating department.
Performs high level and complex work assignments.
Handles specialized claims functions (Molecular claims, time sensitive member reimbursements issues with contracted providers).
Works in conjunction with the training unit on release and of high dollar claim.
Solely responsible for processing SRS LOA claims received from SRS/SHC Finance.
Seeks to understand and address customers' needs, partner to provide workable solutions.
Tracks and responds to health plan appeals, grievances, claims resolutions and 10 day letters.
Researches and resolves complex issues related to claims processing and payment in a timely manner and within established department guidelines.
Responds to inquiries and requests from health plan providers and internal departments received via phone, email or fax.
Researches and resolves provider payment disputes and appeals.
Explains contract status, financial risk and payment methodologies.
Assists with the completion of time sensitive work, demonstrating ability and knowledge in all unit functions.
Supports staff needs due to expected/unexpected absences of supervisors or staff.
Provides unit personnel with training, direction, communication and leadership for the purpose of ensuring complete, accurate and professional performance.
Assists in creating an environment that promotes teamwork, professionalism, competence and communication.
Ensures all regulatory requirements met (state and federal).
Participates in achieving departmental goals.
Works in the spirit of cooperation with all employees of Sharp.
Accepts and/or participates in special projects as requested.
Completes special projects as needed.
Receives and reviews transplant packets to insure all necessary information has been submitted.
Reviews packet against DOFR, authorization and transplant grid for appropriate financial risk at contracted or agreed rate.
Completes individual transplant worksheet listing all claims and payment requirements.
Reviews claim system for potential duplicate claim or adjustments.
Coordinates all of the above to avoid back end recovery.
Works with seven health plans for two medical groups (Sharp Community Medical Group and Sharp Rees-Stealy Medical Group).
Reviews MSP packet to coordinate reimbursement to Medicare.
Includes working with other departments within Sharp HealthCare including but not limited to Institutional Care Division and Community Care Division.
Communicates with/responds to the Department Of the Treasury of the United States as necessary.