PRINCIPAL RESPONSIBILITIES:
Under the general supervision of the Manager, Claims Operation Support, the principal responsibilities of the Claims Specialist include:

Audit Activities:

Audit a designated percentage of all daily processing production for assigned staff members (including errors from claims pricing, adjudication, adjustments, member bill issues, and mail).
Conduct periodic focused claims audits to determine if the correct adjudication decisions were made and initiate necessary actions to alleviate any incorrect decisions
Maintain a record of audit results for each staff member. Provide feedback to appropriate Claims Processing Supervisor or Claims Production Manager for processing staff to correct and/or adjust errors. Submit a monthly summary report of findings to the Claims Processing Supervisor of all errors
As requested, conduct various internal audits and Delegated Group audits according to federal, state and departmental policies and procedures, including DHCS, CMS and DMHC guidelines
Assist Manager in the preparation for all internal, external and regulatory audits.
Ensure compliance and conduct follow up audits based on corrective action plans or previous audit results
Develop summary reports for communicating results and conclusions of completed audit activities. Reports will include audit objectives, scope, findings, conclusions and recommendations

Recovery Activities:

Keep current on CMS, DHCS, DMHC regulations and AAH policies and contracts or letters of agreement language as it pertains to recovery
Initiate and expand recovery opportunities through audits, process enhancements and provider calls in addition to system generated reports
Analyze errors that result in recovery of money to determine their root cause and identify additional recovery opportunities related to the root cause
Work closely with Compliance in the efforts of fraud, waste and abuse investigations and recoveries
Clearly communicate recoveries to providers according to established payment methodologies, division of financial responsibility grids (DOFR), applicable regulatory legislation, claims processing guidelines, contractual agreements and/or AAH policies and procedures

Research and Resolution Activities:
Review, research and resolve various claims projects resulting from provider identified issues or as the result of system configuration changes
Review, research, and resolve complex claims processing issues, including Service Requests, Provider Disputes, member billing issues and adjustment projects.

System Testing Activities:

Assist in the development of test scenarios and test scripts to be used for new software implementation and/or system upgrades
Perform system testing for new software implementation and/or system upgrades.
Perform testing on routine system configuration changes including new provider contracts, provider contract amendments, fee schedule changes and new benefit or program changes

Miscellaneous Activities:

Assist Claims Operations Trainer in creating training guidelines and suggest quality improvements for existing staff
Review, research and apply claim edits from claims processing systems
Demonstrate continuous effort to improve operations, decrease turnaround times, streamline work processes, and work cooperatively and jointly to provide quality guidance to others in the department
Perform other duties and special projects as specified by the Director, Claims and/or Manager, Claims Operations Support

ESSENTIAL FUNCTIONS OF THE JOB

Audit, research and maintain the record of audit results
Assist with audits of internal or delegated claims processing
Initiate and pursue recovery opportunitites
Assist in testing of new software implementation and/or system upgrades
Analysis of claims data and application of claim policy
Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls

PHYSICAL REQUIREMENTS

Constant and close visual work at desk or computer
Constant data entry using keyboard and/or mouse
Constant sitting and working at desk
Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person
Frequent lifting of folders and other objects weighing between 0 and 20 lbs
Frequent walking and standing

Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:

High School Diploma or equivalent is required.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

Three to five years in a managed care claims processing environment required, including the processing of all medical claim types and the handling of complicated claims issues

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

Knowledge of organizational and departmental operations, reimbursement and legal/regulatory guidelines
Understanding of State and CMS regulatory requirements
Strong claims processing auditing experience
Must have detailed knowledge of CPT, HCPCS, RVS, ICD-10, CMS1500/UB04 coding and forms
Ability to correctly interpret claims processing rules, regulations, and procedures
Ability to plan and execute projects independently
Ability to communicate effectively, both verbally and in writing
Ability to handle multiple projects and balance priorities as well as work for a number of individuals.
Excellent writing and editing skills and ability to summarize complex information clearly and accurately
Well organized and detail oriented.
Knowledge of Medi-Cal guidelines and processing
Excellent critical/analytical thinking and problem-solving skills
Proficient experience in Microsoft Office products
Knowledge of and experience with HealthSuite application preferred

SALARY RANGE $33.46-$50.20 HOURLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.