JOB
Description
Under the direction of the Claims Supervisor, the Claims Analyst II performs a variety of research, auditing and resolution activities related to the claims processing function. These activities include, but are not limited to, responding to inquiries related to claim submissions and processed claims, working on various claims projects and identifying claim errors, root causes and recommended solutions. The Claims Analyst II coordinates with Xerox/ACS Claims staff and Gold Coast Health Plan (GCHP) Provider Relations to resolve provider claims issues. EXAMPLE OF DUTIES
Duties and Responsibilities:
- Serves as a Claims subject matter expert in researching claims issues escalated from Xerox/ACS or from GCHP Provider Relations.
- Researches claims issues in coordination with designated Xerox/ACS Claims leadership in accordance with GCHP and Xerox/ACS policies and procedures, Medi-Cal requirements and industry standards for Claims adjudication.
- Assists Xerox/ACS Claims in determining proper courses of action in resolution of Provider claims issues.
- Assures timely and accurate resolution of claims issues jointly with Xerox/ACS Claims and/or configuration staff.
- Creates or updates claim-related policies, procedures and workflows.
- Works on provider claims research projects.
- Initiates direct communication with providers when additional information is required. Communicates with providers on resolution and closure of issues, as needed.
- Participates in GCHP and Xerox/ACS meetings established to coordinate and track provider complaints, as needed.
- Performs daily/weekly prepayment audit of claims within the guidelines provided and assists in the development and enhancement of the prepayment audit programs for oversight and monitoring of ACS and coordination of weekly check run processes.
- Performs post payment auditing in accordance with GCHP audit programs.
Attends JOCs/JOMs with providers, as required.
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Job-Related Qualifications
Knowledge of:
- Medi-Cal eligibility and benefits.
- Medical billing/coding (CPT, HCPCS, ICD-9/ICD-10); COB/TPL regulations and guidelines.
- All claim types and standard claims adjudication practices.
- Provider reimbursement methodologies.
- Medi-Cal regulations; working knowledge of Medicare (CMS), and commercial (DMHC). Also requires knowledge of health plan division of financial responsibility (DOFR), and industry “best practices.”
Computer skills that include MS Office products.
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Ability to:
- Assist in the creation of policies, procedures and workflows.
- Work in a fast paced, diverse organization that is performance oriented.
- Remain knowledgeable of the health plan’s benefit structure.
- Communicate effectively verbally and in writing.
- Organize own work, set priorities, meet critical deadlines, and follow-up on assignments with a minimum of direction.
