Mail Clerk, Sr. jobs in Sacramento, CA

Job Title: Mailroom/Claims Support Clerk - In-office 
Location: Rancho Cordova, California

Summary: The Mailroom/Claims Support Clerk is a key part of a successful operation for Lucent Health.   The Mailroom/Claims Support Clerk is in daily contact with all team members, managers, directors and executive level members. This position reports to the Appeals Supervisor and is responsible for reviewing, analyzing and routing claims for pre services and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non-clinical services, quality of service and quality of care issues to include executive and regulatory.  Attention to detail, organization, self-direction, and the ability to meet time deadlines are essential qualities of this position.   Attendance directly impacts the satisfaction level of our clients, the productivity of our staff and the retention of our accounts.

Essential Duties and Responsibilities: (Other duties may be assigned)

• Reviews, analyzes and routes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language. 
• The grievance and appeal work are subject to applicable accreditation and regulatory standards and requirements. As such, the clerk will strictly follow department guidelines and tools to conduct their reviews. 
• Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination. 
• Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information. 
• Interpret Plan Documents and review appeals within guidelines and timeframes as determined by the clients plan coverage
• Maintain and or develop workflows with comprehensive notes with attention to detail to enable accurate claims processing related to appeals and or refunds
• Maintain quality and production standard when processing appeals and client refunds 
• Support the Office Administrator as backup when unavailable by opening, sorting, batching incoming mail.  Prepares and processes outgoing mail (including postage). This process is further defined as Inventory control by organizing, tracking and reporting all of the inbound claims and correspondence.    
• Prints incoming faxes for imaging and distribution.   
• Quickly develops the ability to correctly recognize, sort and distribute inbound and outbound letters, forms and materials.  
• Scans and forwards to appropriate examiner/department: COB information, letter responses and TPL (third party liability) responses.
• Re-directs G-tess reject batches to examiner. 
• Emails examiners/associates batch numbers of scanned claims.
• Prints letters for COB, TPL and Recoups and process for mailing.
• Complies with company policies and procedures as outlined in the Employee Handbook.
• Complies with department policies and procedures.
• Performs special projects at the request of management. 
• Operates multiple pieces of equipment including postage machines.
• Completes research to properly route inbound claims and other materials to correct people, departments or systems.
• Produces and prepares copies of materials as appropriate or as assigned.
• Exhibit an attention to detail and a strong work ethic
• Regular, predictable attendance is required.
• Ability to get along and work effectively with others.
• Complete other duties as assigned. 

Supervisory Responsibilities: This job has no supervisory duties.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience: Previous Claim processing experience is required. Have thorough knowledge of coding structures (CPT, HCPCS, Revenue codes, ICD 9/10 etc.); as well as COB payments and distribution of funds. Ability to understand all types of claims pricing (Network, Medicare, UCR etc.)

Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals.  Ability to write routine reports, and correspondence. Ability to speak effectively before groups of customers or employees of the organization. 

 Mathematical Skills: Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.  Ability to apply concepts of basic algebra and geometry.

Reasoning Ability: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills: To perform this job successfully, an individual should have knowledge of Internet software and the Microsoft Office Suite of products. Knowledge of basic office equipment should include: Internet and email, copy and fax machines, postage meter and telephone.         

Physical and Emotional Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The inability to cope with a stressful work environment does not constitute a protected disability.

While performing the duties of this job, the employee is frequently required to sit. The employee is required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; stoop, kneel, and talk or hear. The employee must occasionally lift and/or move up to 10 pounds.  Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 The noise level in the work environment is usually quiet