Claims Representative Senior - Remote in CA & NV
About the position
The position involves performing complex research and analysis of claims to resolve disputes related to healthcare services. The role requires collaboration with various departments to ensure payment integrity and compliance with healthcare regulations. It is a full-time role with flexibility in work hours, primarily focused on improving health outcomes and supporting the organization's mission of advancing health equity.
Responsibilities
Perform complex and extensive research, analysis, and logical conclusions of paper and electronic claims to resolve disputes.
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Conduct necessary follow-up with internal departments to validate payment integrity related to regulatory agencies, contracts, policy, coding, and system configuration.
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Act as a department resource and support Customer Service in resolving Practice Connect issues.
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Respond to provider calls related to disputes and appeals for incoming provider/member disputes.
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Identify, trend, and report the Provider Dispute and Resolution process for management, preparing reports summarizing observations and recommendations for quality improvement.
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Provide qualified data to the Business Operations Compliance & Regulatory Manager for training programs and policies.
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Confer with management to assess training needs in response to identified trends.
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Collaborate with other departments and management to implement and reinforce policy quality standards.
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Maintain regular and consistent attendance.
Requirements
High School Diploma or GED required.
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Must be 18 years of age or older.
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Claims adjudication experience is required.
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Knowledge of different lines of business including Commercial, Medi-Cal, Medicare, and medical procedure codes.
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3+ years related experience with intermediate to advanced knowledge of claims processing, compliance, and regulatory governing agencies (CMS, DMHC, DHS).
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4+ years of medical claims knowledge is required.
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Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
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Knowledge of healthcare regulations and guidelines including CMS, DHCS, and DMHC as pertains to AB1455.
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Ability to work any shift between the hours of 8:00 AM - 5:00 PM PST from Monday - Friday.
Nice-to-haves
Benefits
Comprehensive benefits package
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Incentive and recognition programs
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Equity stock purchase
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401k contribution
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