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Partnership HealthPlan of California · 1 day ago

Claims Resolution Coordinator

Sonoma County, CA

Full-time

Onsite

Mid Level

$37.22/hr - $46.53/hr

4+ years exp

Partnership HealthPlan of California is seeking a Claims Resolution Coordinator to research and resolve complex claims issues. This role involves developing training materials for providers, conducting training sessions, and serving as a resource for customer service and provider relations staff.

Health CareInsuranceNon Profit

Culture & Values

Responsibilities

Answers customer service lines as necessary and responds to provider inquiries either by phone, email, or in person regarding claims related questions

Reviews, researches, and works with various departments to resolve complex provider inquiries, appeals, and grievances

Acts as a resource and provides support to customer service staff, as well as Provider Relations staff for complex Provider questions regarding claims and payments

Coordinates with Claims, Member Services, Health Services departments, the development, maintenance, and training of ongoing educational materials and tips for inclusion on the Partnership website. Incorporates educational materials into the PR Manual and updates on a quarterly basis

Processes CIF's and adjustments as needed

Writes and runs reports in Business Objects to obtain needed claim data

Tracks and analyzes provider trends with denials and CIF's to provide support to providers with an opportunity to improve. Distributes provider scorecards

Tracks complaints, appeals, and grievances by program. Reports activities on a quarterly basis to IQI, Partnership Compliance Coordinator, and Claims Director

Presents findings and recommendations for ongoing, long term resolutions to issues. Identifies items to address the 'provider hassle factor.'

Acts as liaison and meets with designated staff from Claims, Health Services, Member Services, and QI departments to identify ongoing provider issues

Coordinates system issues with Claims Configuration staff, IT staff, and PR Lead Project Specialist/Auditor. Leads or participates in special projects as needed

Other duties as assigned

Qualification

Claims examining experienceMedi-Cal claims processingCPT coding knowledgeICD-9 coding knowledgePartnership Claim Policy knowledgeCommunication skillsAnalyze claimsTyping speed 30 wpm10-key calculator proficiencyOrganization skills

Required

Minimum four (4) years claims examining experience

Three (3) years Partnership CSR III or above claims experience and completion of Partnership claims training

Equivalent combination of education and experience

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

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

Ability to use a computer keyboard

Ability to lift 25 lbs

Periodic travel and overnight stays may be required

Preferred

College course work in business or related field

Company

Partnership HealthPlan of California

Partnership HealthPlan of California is a non-profit community-based health care organization that contracts with the state to administer Medi-Cal benefits through local care providers to ensure Medi-Cal recipients have access to high-quality comprehensive cost-effective health care.

Founded in 1994

Fairfield, California, USA

1001-5000 employees