Overview

To review, research, and resolve claims for all Medi-Cal claim types within established production and quality standards, including manual processing. Creates appropriate documentation that reflects the actions taken and status of the claim. Generates provider communication, such as letters. Routes and tracks claims requiring review by other staff and departments, and processes when possible.

Responsibilities

• Reviews, researches, and resolves pended claims for Medi-Cal types: medical, ancillary, long term care, CHDP, encounter data, other coverage, and batch claims within established production and quality standards. Completes claims from the Batch Error Report and Batch Pass Report.
• Routes claims to appropriate PHC departments and internal staff for additional review. Follows up and completes claims once response to request has been received.
• Follows established PHC policies and procedures, PHC Claims Operating Instruction Memorandums, State of California Medi-Cal Provider Manual guidelines, Title 22 regulations, and CMS guidelines when resolving pended claims.
• Generates claims correspondence as needed.
• Records daily production statistics and related activities on appropriate reports. Turns in all logs and reports to the Medi-Cal Claims Supervisor.
• Reviews all work audits in a timely manner and submits any adjustments and corrections within the allotted time frame.
• Supports Claims Department’s needs for resolving all pended claim types.
• Participates in special projects and assignments as required.
• Other duties as assigned.

Qualifications

Education and Experience

High school diploma or equivalent; prior experience examining claims in an automated environment; or equivalent combination of education and experience.

Special Skills, Licenses and Certifications

Effective written and oral communication skills. Good organization skills.

Performance Based Competencies

Ability to effectively exercise good judgement within scope of authority and handle sensitive issues with tact and diplomacy. Ability to stay focused on repetitive work and meet production and quality standards. Ability to accurately complete tasks within established timelines.

Work Environment And Physical Demands

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.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

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.