Claims Specialist,Senior

DaVita Medical Group - El Segundo, CA

Responsible for processing, auditing, and adjusting all professional and facility medical claims, appeals and prepayment audits. Answers incoming telephone inquiries, and accurately and thoroughly documents problems and resolutions. Troubleshoots claims that have been identified as needing additional work in the areas of eligibility, referral authorization and contracting or provider set-up. Trains and assists other analysts with problem claims and escalated telephone calls.

Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
Processes all types of medical claims and adjusts medical disputed claims (Professional and Facility) according to department, contract, and regulatory requirements.
Performs prepayment audit on all types of medical claims (Professional and Facility) according to department, contract, and regulatory requirements
Answers telephone inquiries through the “Automated Call Distributor (ACD) Telephone System” as needed
Identifies individual provider needs and take appropriate steps to satisfy those needs.
Updates authorization information based on information obtained from provider.
Troubleshoots problem claims to resolve provider issues or systematic issues.
Verifies and interprets information in all vendor contracts to resolve issues.
Trains analysts and monitors general office support functions as needed.
Analyzes work processes, identifies areas needing improvements and initiates necessary steps to make changes.
Participates in the continuous quality improvement of IMCS core business system.
Follows unit procedures for performing call processing, claim adjustments and denials and references Policies and Procedures, job aides, provider contracts, and other reference materials to assure complete and accurate decisions.
Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.

High school diploma, G.E.D. or equivalent. Includes special certification required for specific jobs.

Over 5 years and up to and including 7 years of experience in an indemnity and / or HMO setting processing, auditing or adjusting professional claims.

Experience in an indemnity and / or HMO setting processing, auditing, or adjusting facility claims.

Computer literate.
Knowledge of Microsoft Office products.
Individual must be reliable, dependable, and punctual.
Excellent customer service and telephone skills.
Excellent verbal and written communication skills.
Ability to work in an environment with fluctuating workloads.
Ability to solve problems systematically, using sound business judgment.
Ability to make decisions with every call and handle escalated issues.
Ability to make decisions regarding escalation of referrals to Care Management.
Familiarity with ICD-9 and CPT codes.
Knowledge of all types of professional claims
Ability to research and verify claims payment issues.
Knowledge of compliance related to the processing of claims.
Knowledge of medical terminology and pricing options.
Knowledge of different sources of authorization documentation.
Ability to update authorization information based on information obtained from facilities.
Ability to read and interpret all vendor contracts.
Knowledge of DRG pricing.