Claims Administration Specialist

Duties & Responsibilities

• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Maintains adequate information in company systems and ensures data collection, summarization, integration and reporting, which includes case creation and management and events/activity tracking.
• Gathers pertinent information regarding the grievances and appeals received, including member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal or supplemental information required to evaluate grievances and appeals within regulatory requirements.
• Covers case discussions with operational experts to result in a final case disposition as needed.
• Evaluates case details, proposes recommendations or makes decisions as applicable and ensures the organization's decision is implemented according to the Grievance and Appeals policies and case resolution.
• Develops resolution letters and correspondence to members and providers.
• Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals.
• Contacts appropriate parties to request and obtain missing information and supporting documentation or provides education.
• Reads and interprets provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions.
• Responds to routine provider inquiries via phone, assisting with provider appeals resolution inquiries.
• Affords assistance with the health networks' compliance process.
• Identifies trends and root causes of issues, proposes solutions or escalates ongoing issues to management.
• Mets performance measurement goals for Grievance and Appeals Resolution Services.

Requirements

• High school diploma or equivalent PLUS 1 year of experience with Provider Dispute Resolution in Medicare and Medi-Cal in professional, institutional, outpatient, ancillary, coordination of benefits and government cases required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
• 1 year of experience with Medicare or Medi-Cal provider appeals and denials process required.
• 1 year of experience in any of the following areas: Grievances and Appeals, Claims Administration, Regulatory Compliance, Customer Service or related field required.
• Associate degree in business, health care administration or related field.
• Experience in health care practice standards, for both government and commercial plans.
• Bilingual in English and in one of company-defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).