Job Details
Job Location
Corporate Headquarters - Chula Vista, CA
Salary Range
$26.03 - $29.93 Hourly
Description
POSITION SUMMARY
Assists Claims Compliance Supervisor to ensure claims compliance is met with all the regulatory requirements for Medicare and Medi-Cal. Addresses second level provider disputes, based on CHG's protocols and regulatory requirements. Performs daily audits, analyzes reports, distributes work, and identifies training needs for the Provider Services and Claims department.
COMPLIANCE WITH REGULATIONS:
Works closely with all departments necessary to ensure that processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and Medi-Cal.
RESPONSIBILITIES

• Monitor reports to identify productivity, paper disputes acknowledgment, determination letter and payment turnaround time.
• Distributes work and ensures provider disputes are resolved in a timely manner.
• Prepares and analyze monthly/quarterly reports on department progress.
• Coordinates with internal and external stakeholders and performs root-cause analysis to support department goals.
• Assists with regulatory reports including monthly compliance dashboard and state supplemental files.
• Conducts monthly audits on the provider dispute module to ensure compliance with applicable regulations.
• Audits provider dispute analysts and Claims auditors for quality assurance purposes.
• Identify training opportunities for the Provider Dispute and Claim Audits teams and submit recommendations to the Claims Compliance Supervisor.
• Responsible for second level review determination and DMHC Provider Complaints.
• Assists supervisor with desktop procedures specific to provider disputes and claim audits.
• Performs secondary review on high dollar claims ($100k ) and releases for payment.
• Monitor delegate provider dispute performance on a quarterly and annually basis.
• Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.

Qualifications
Education:

• High school diploma or equivalent training.
• Bachelor's Degree preferred.

Experience/Skills:

• A minimum of three years of experience in Provider Disputes.
• A minimum of five years of experience in Claims Adjudication including professional and institutional claims for Medi-Cal or Medicare lines of business
• Strong knowledge of AB1455 regulatory requirements, CPT and ICD10 coding, Medi-Cal and Medicare claim regulations
• Ability to read, analyze and interpret regulations and contract language.
• Excellent customer service skills.
• Good technical writing skills.
• Good judgment and problem-solving skills; team player; and ability to work independently.
• Ability to prioritize tasks

Physical Requirements:

• Prolonged periods of sitting and frequent walking.
• May be required to work evenings and weekends.

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action