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Partnership HealthPlan of California · 5 hours ago

Claims Customer Service Representative III

Sonoma County, CA

Full-time

Onsite

Entry, Mid Level

$32.51/hr - $39.01/hr

1+ years exp

Partnership HealthPlan of California is seeking a Claims Customer Service Representative III to manage and process CIF claims. The role involves researching and resolving claims issues, participating in provider meetings, and ensuring compliance with established policies and procedures.

Health CareInsuranceNon Profit

Culture & Values

Responsibilities

Research, resolve, and communicate outcome to providers on CIFs, claim tracers, and general claim correspondence within established timeframes

Participate in provider meetings to resolve claim issues. Along with Provider Relations staff, participate in quarterly provider focus group meetings and in-services

Follow established Partnership policies and procedures, Partnership claims operating instruction memorandums, EDS provider manual guidelines, and Title 22 regulations when resolving claims and claim issues. Complete claim processing accurately within established production standards

Enter, process, and resolve claims from all Partnership CIF claim types and in any form (paper or electronic) within established standards. This will include electronic and paper crossover claims, pended claims, and claims which require manual pricing

Participate in special projects and assignments as required

Recognize and give feedback to management on procedure changes that would result in more efficient operations

Record daily production statistics and related activities on appropriate reports; turn all logs and reports in to Claims Customer Service Supervisor

To provide support to CSR staff when call volume requires additional personnel

At the Supervisor’s discretion and Manager’s approval, a CSR III will be authorized to adjust their CIF’d claims. This authorization will be limited in scope to only those claim types they have demonstrated proficiency in and are consistently meeting both their quality and production goals

Qualification

Claims processing experienceCPT codingICD-9 codingMedical terminologyTyping speed 30 wpm10-key calculator proficiencyJudgmentEffective communication skillsOrganization skills

Required

High school diploma or equivalent

Minimum one (1) year of prior claims processing experience in an automated claim environment; or equivalent combination of education and experience

Knowledge of CPT, HCPC procedure coding, and ICD-9 diagnostic coding

Knowledge of medical terminology

Ability to access coding reference guides for accurate information

Typing speed 30 wpm and proficient use of 10-key calculator

Effective written and oral communication skills

Ability to effectively exercise good judgment within scope of authority and handle sensitive issues with tact and diplomacy

Good organization skills

Ability to accurately complete tasks within established times

Ability to use a computer keyboard

More than 80% of work time is spent in front of a computer monitor

When required, ability to move, carry, or lift objects of varying size, weighing up to 5 lbs

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