Claims Service Representative

Description

Job Summary (General Overview, reporting to, work environment)
Under the general supervision of the Claims Service Supervisor, this position is responsible for responding to all CenCal Health Provider telephone inquiries, researching and responding to all claims issues raised, performing regular monthly meetings with the provider community, assisting with provider workshops preparing educational materials and providing suggestions for the Claims Bulletin and EOB inserts (fliers) when necessary; research and resolve provider disputes, higher level reviews and stay current with all CenCal Health policies and procedures.

Duties and Responsibilities

• Intake and respond to all provider telephone inquiries
• Log all calls received and initiated in the Provider Call Tracking system within Oracle and maintain accurate accounts of conversations within the log for tracking purposes
• Research, adjudicate and respond to all claims issues related to telephone inquiries, disputes, NCM and provider emails in a timely manner
• Log all check tracers and supply data to Finance. Follow up in 30 days if not resolved.
• Send provider EOPs when requested
• Review test Explanation of Payment (EOPs) for accuracy of claims payment, denials and suspends
• Monitor provider billing errors, trends and provide courtesy calls to providers when possible problems or trends are detected
• Assist with pended claims when necessary
• Conduct meetings with Providers that are experiencing a high volume of denials, that have new billers, or any provider requesting assistance with any type of claim related issues. Compose letters to those providers visited. Conduct and outline discussions during the meeting and perform any follow up that may have been required
• Analyze providers claims to assure the most accurate, timely and efficient processes are occurring and work directly with the providers where improvement may be needed
• In conjunction with the Claims Service Supervisor, prepare and occasionally present at the Claims Provider Workshops
• Complete special projects within the department when necessary
• Complete processes and timelines required by AB1455 Claims Settlement Practices and DHCS Regulations
• Other duties and projects as assigned by the Claims Customer Service Supervisor, Claims Operations Manager and/or Director of Claims Operations

Qualifications

Skills/Knowledge/Abilities

• Excellent customer service skills
• Strong oral and written communication skills (including the ability to speak in front of an audience)
• Excellent attention to detail
• Demonstrated ability to perform special claims projects
• Knowledge of CenCal Health and the Medi-Cal program is strongly preferred

Core Competencies

• Continuous Learning: Spends time and energy to learn new approaches, tools, and methodologies to stay abreast and move ahead in position/field.
• Computer Skills: Ability to quickly assimilate and use computer operating systems and applications. Advanced skills with computer programs including MS Excel, Word, PowerPoint and Outlook.
• Interpersonal /Customer Services Skills: Treats others with courtesy, sensitivity and respect. Considers and responds appropriately to the needs and feelings of different people in different situations. Nurtures internal and external customers to develop confidence, trust and long-term relationships/partnerships.
• Initiative & Motivation: Displays strong personal initiative and motivation to achieve desired performance results. Takes on tasks and assumes responsibility without being asked to do so. Takes charge in the absence of detailed instructions and/or plans.
• Results Orientation: The ability to focus on the desired result of ones own or ones units work, setting challenging goals, focusing effort on the goals, and meeting or exceeding them.
• Thoroughness: Ensuring that ones own and others work and information are complete and accurate; carefully preparing for meetings and presentations; following up with others to ensure that agreements and commitments have been fulfilled.
• Flexibility: Displays ability to quickly adapt to changing requirements, special assignments and workload re-prioritization. Openness to different and new ways of doing things; willingness to modify ones preferred way of doing things.
• Walk the Talk: Do what you say you are going to do. Be accountable for your actions.
• World Class Mindset: Behaves in an honest, fair, and highly ethical manner. Shows consistency in words and actions. Punctual, exhibits professional email etiquette. Adhere to company and department standards. Commitment to excellence.

Education and Experience

Required:

• High school diploma or equivalent
• Minimum one (1) year of claims processing experience or equivalent medical billing background

Desired:

• Call center/phone experience highly desirable
• Prior experience in high volume, production environment

Essential Functions (Consider sitting, standing, travel, working at computer for long periods of time, lifting etc.)

• Physical requirements needed to perform the essential functions of this job, with or without accommodation:
  • Mbility Requirements: ability to operate a keyboard and sit for long periods; stand, sit, reach, bend, crawl, stoop, lift up to 10 lbs.
  • Visual Requirements: ability t read close-up and do close-up work
  • Dexterity Requirements: ability t perform repetitive motion (keyboard); writing (note-taking)
  • Hearing/Talking Requirements: ability t hear normal speech, hear and talk on the telephone
  • Emtional/Psychological Requirements: ability to deal with public contact, in person and Normal office environment. Must be able to sit and work at a computer for long periods of time
• Must be able to travel outside the office and attend meetings during and after regular work hours
• Regular attendance is essential to perform this job
• Possess a current, valid drivers license with a clean driving record