Appeal Resolution Specialist jobs in Vallejo, CA

Overview

To research and resolve complex claims issues which cross interdepartmental lines and communicate the outcome to providers and affected PHC managers. Develops and maintains provider training materials for all lines of business. Conducts provider trainings across PHC departmental lines in group or individual provider settings.

Responsibilities

• Answers customer service lines as necessary and respondsto provider inquiries either by phone, email,or in person regarding claims related questions.
• Reviews, researches, and works with various departments to resolve complex provider inquiries, appeals, and grievances.
• Acts as a resource and provides support to customer service staff, as well as Provider Relations staff for complex Provider questions regarding claims and payments.
• Coordinates with Claims, Member Services, Health Services departments, the development, maintenance, and training of ongoing educational materials and tips for inclusion on the PHC website. Incorporates educational materials into the PR Manual and update on a quarterly basis.
• Processes CIF's and adjustments as needed.
• Writes and runs reports in Business Objects to obtain needed claim data.
• Tracks and analyzes provider trends with denials and CIF's to provide supportto providers with an opportunity to improve. Distributes provider scorecards.
• Tracks  complaints, appeals, and grievances by program. Reports activities on a quarterly basis to IQI, PHC Compliance Coordinator,and Claims Director.
• Presents findings and recommendations for ongoing, long term resolutions to issues. Identifies items to address the “provider hassle factor.”
• Acts as liaison and meets with designated staff from Claims, Health Services, Member Services, and QI departments to identify ongoing provider issues.
• Coordinates system issues with Claims Configuration staff, IT staff,and PR Lead Project Specialist/Auditor. Leads or participates in special projects as needed.
• Other duties as assigned

Qualifications

Education and Experience

Minimum four (4) years claims examining experience; three (3) years PHC CSR III or above claims experience and completion of PHC claims training; or equivalent combination of education and experience; College course work in business or related field preferred.

Special Skills, Licenses and Certifications

Familiarity with Medi-Cal and/or managed care claims processing. Knowledge of CPT, HCPC procedure coding, and ICD-9 diagnostic coding. Knowledge of PHC Claim Policy and Procedures, Medi-Cal provider manual guidelines, Title 22 regulations and any other required policies, procedures, regulations, and manuals. Typingspeed 30 wpm and proficient use of 10-key calculator. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Ability to analyze and research claims issues. Excellent written and oral communication skills. Ability to present statistical and technical data in a clear and understandable manner. Good organization skills. Ability to work on multiple assignments simultaneously, prioritize work and complete projects within established time frames. Use good judgment in making decisions within scope of authority and handle sensitive issues with tact and diplomacy.

Work Environment And Physical Demands

Ability to use a computer keyboard. More than 70% of work time is spent in front of a computer monitor. Ability to lift 25lbs. Periodic travel and overnight stays may be required.

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.

HIRING RANGE:

$ 65,516.97 - $ 85,170.87

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.