Job Details

Responsible for the review and processing of regular claims using established claim standards and departmental policies and procedures ensuring that the work is performed accurately and delivered to meet set objectives.

Essential Duties and Responsibilities

• Work with multiple departments in the hospital to audit and/or evaluate compliance with federal and state rules and regulations related to claims.
• Track outstanding issues identified in claims compliance audits and issue reports and appropriate recommendations and/or conclusions to the Compliance/Privacy Officer, department leaders, and the Corporate Compliance Committee.
• Assist in the development, execution and follow-up of action plans, education to improve performance.
• Performs routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory standards and timelines, business policy, contract, appropriate coding, and system configuration with ability to extract and audit exception audit reports.
• Research claim processing problems and errors to determine their origin and appropriate resolution.
• Prepare reports and summarizes observations for management summarizing observations and recommendations.
• Identifies and escalates issues related to instructional material that is inaccurate, unclear or contains gaps.
• Provides recommendations for correction of this material.
• Confers with management to assess training needs in response to changes in policies, procedures, regulations, and technologies.
• Maintains a minimum audit accuracy rate.

Qualifications

• Minimum 5+ years Medical Claims experience is required.
• Experience working with Medicare / Medicaid / HMO/Commercial/ Affordable Care Knowledge of healthcare regulations and guidelines including Medicare, Medi-Cal, Commercial insurance.
• Experience with HCF1500 and UB-92 claim forms, and CPT Coding.
• Have knowledge of medical terminology, CPT, HCPCS, ICD-10, DRG, CCI edits.
• Knowledge of MTR, ODAG, PDR reporting.
• Has basic knowledge of theories, practices and procedures related to claims/ claims quality Intermediate skill levels in MS Word, Excel, and Outlook required.
• Programming / database skill is highly preferred.
• Knowledge, Skills, and Abilities: Able to work well with others in a collaborative and respectful manner.
• Detail-oriented, precise, and thorough.
• Knowledge of Medicare, Medi-Cal, Commercial insurance reimbursement requirements and guidelines.
• Able to multi-task, deal with complexity on a frequent basis.
• Essential to perform all functions of the job accurately and in a timely manner.
• Able to work under pressure and time constraints.
• Able to arrive for work on time and maintain a good attendance record.
• Ability to maintain a professional demeanor and confidentiality

Physical Requirements

• Able to lift up to 30 pounds
• Use proper body mechanics when handling equipment
• Standing, walking and moving 50% of the day.

Compliance Requirements

Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.

Base Pay Scale

Starting at $31.41 – $40.98 per hour.
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.