Claims Analyst Ii

Gold Coast Health Plan will not sponsor applicants for work visas

POSITION SUMMARY

Under the direction of the Claims Manager, the Analyst II, Claims, 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 Analyst, Claims II, coordinates with Xerox/ACS Claims staff and Gold Coast Health Plan (GCHP) Provider Relations to resolve provider claims issues.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statement(s)

• 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.

POSITION QUALIFICATIONS Competency Statement(s)

• Analytical Skills - Ability to use thinking and reasoning to solve a problem.

• Business Acumen - Ability to grasp and understand business concepts and issues.

• Research Skills - Ability to design and conduct a systematic, objective, and critical investigation.

• Communication, Oral - Ability to communicate effectively with others using the spoken word.

• Communication, Written - Ability to communicate in writing clearly and concisely.

• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

SKILLS & ABILITIES

Education: High School Graduate or General Education Degree (GED): Required

Experience: 5 plus years of experience in a claims processing department. Medi-Cal/Medicaid managed care experience strongly desired.

Any combination of experience and training that would provide the required knowledge, skills, and abilities would be qualifying.

Requires 5-7 years experience

Computer Skills: Computer proficiency included in the MS Office programs.

Certifications & Licenses: A current and valid California Driver's License and Insurance.

Other Requirements: 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.”