Claims Resolution Coordinator

Responsibilities

• Answer customer service lines as necessary and respond to provider inquiries regarding claims related questions.
• Review, research, and work with various departments to resolve complex provider inquiries, appeals, and grievances.
• Act as a resource and provide support to customer service staff, as well as Provider Relations staff for complex Provider questions regarding claims and payments.
• Cook up and maintain provider training materials for all lines of business.
• Conduct provider trainings across Partnership departmental lines in group or individual provider settings.
• Coordinate with Claims, Member Services, Health Services departments, the development, maintenance, and training of ongoing educational materials and tips for inclusion on the PHC website.
• Incorporate educational materials into the PR Manual and update on a quarterly basis.
• Process CIF's and adjustments as needed.
• Write and run reports in Business Objects to obtain needed claim data.
• Track and analyze provider trends with denials and CIF's to provide support to providers with an opportunity to improve.
• Distribute provider scorecards.
• Track complaints, appeals, and grievances by program.
• Report activities on a quarterly basis to IQI, PHC Compliance Coordinator, and Claims Director.
• Present findings and recommendations for ongoing, long-term resolutions to issues.
• Identify items to address the "provider hassle factor."
• Act as liaison and meet with designated staff from Claims, Health Services, Member Services, and QI departments to identify ongoing provider issues.
• Cook up system issues with Claims Configuration staff, IT staff, and PR Lead Project Specialist/Auditor.
• Lead or participate in special projects as needed.

Qualifications

• Minimum 1 year of experience in claims examining or customer service within healthcare, insurance, finance, or managed care environment; or equivalent combination of relevant experience and education.
• Familiarity with Medi-Cal and/or managed care claims processing.
• Knowledge of CPT, HCPC procedure coding, and ICD-9 diagnostic coding.
• Knowledge of Partnership Claim Policy and Procedures, Medi-Cal provider manual guidelines, Title 22 regulations and any other required policies, procedures, regulations, and manuals.
• Typing speed 30 wpm and proficient use of 10-key calculator.
• Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

• Ability to analyze and research claims issues.
• Excellent written and oral communication skills.
• Ability to present statistical and technical data in a clear and understandable manner.
• Good organization skills.
• Ability to work on multiple assignments simultaneously, prioritize work and complete projects within established time frames.
• Use good judgment in making decisions within scope of authority and handle sensitive issues with tact and diplomacy.

Work Environment And Physical Demands

• Ability to use a computer keyboard.
• More than 60% of work time is spent in front of a computer monitor.
• When required, ability to move, carry or list objects of varying size, weighing up to 5 lbs.

Hiring Range

$37.22 - $46.53

Important Disclaimer Notice

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.