Lead Claims Specialist

Overview

To support the Claims Department in maintaining pended claims, corrected claim inquiries and claims adjustment projects within established guidelines. Reviews and processes complex claims, supports claims examining, while offering additional training or support to the Claims Specialist Team.

• Researches and processes claim adjustment requests
• Participates in special claim adjustment projects as assigned
• Assists in maintaining pended claim reports and files within established department guidelines and program policies
• Performs claims examining functions
• Cross trained and functional in all Partnership claim types
• Complete audits of the Specialist staff as requested
• Performs claims customer service functions as assigned
• Assists in training claims staff as needed
• Monitors efficiency of operations and provides feedback to management on possible effective procedure changes
• Records daily production statistics and related activities on appropriate reports
• Answers questions of the Specialist Staff in a timely and efficient manner utilizing eROUTES
• Monitor and report CIF Inventory weekly
• Review aging CIFS and research reasons for aging; communicate any CIFS over 10 days this with the CSR Manager
• Prepare meeting agendas for Specialist Meetings as requested
• Maintain established guidelines of claims production and quality
• Other duties as assigned.

Education and Experience

Minimum three (3) years claims examining experience; or Partnership claims examining experience and completion of Partnership 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 Partnership claim policy and procedures, EDS provider manual guidelines, Title 22 regulations and any other required policies, procedures, regulations, and manuals. Typing speed 30 wpm and proficient use of 10-key calculator. Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Excellent oral and written communication skills. Ability to effectively exercise good judgement within score of authority and handle sensitive issues with tact and diplomacy. Ability to work on multiple tasks within established time frames and sometimes with competing priorities. Good organization skills with ability to maintain accurate records and documentation of actions and decisions.

Work Environment And Physical Demands

Ability to use a computer keyboard; more than 80% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying sizes, weighing up to 25 lbs. Ability to attend off‑site meetings as required.

All Health Plan 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 Health Plan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$37.22 - $46.53

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.