Under general supervision, provides claims specialized tasks relevant to an assigned program and/or project. This position has analytical, claims expertise, and/or administrative responsibilities specific to the functional area to which assigned. This position is assigned to both the Medi-Cal, Crossover Medicare, and OneCare Connect claims related program and project and involves specialized background or knowledge regarding claims processing rules/logic, business user system testing expertise, and regulatory guidelines relevant to the assignment. The incumbent often works independently and performs more complex analytical, and/or administrative responsibilities. The incumbent will need to exercise discretion and judgment and may coordinate/supervise a function and the work of others within the program or representing the program/project.
• Works in conjunction with Claims Management team, Claims Project Analysts, Contracting, Provider Relations, Coding Initiatives and/or Information Systems to implement benefit or process changes that impact system configuration due to federal and state notices.
• Performs system research and testing to ensure regulatory, coding, contract updates and configuration changes are producing expected results; ensures that all documentation accurately reflects the current status of changes and outstanding issues identified during testing.
• Communicates to claims management team, training and staff regarding any system enhancements or changes. This includes any process deficiencies identified from claims look back analysis and UAT testing.
• Assists the Claims Management team in identifying training and development of desktop procedures and policies for the Medi-Cal and Medicare lines of business impacted by system and/or regulatory changes.
• Provides analytical support and technical expertise on requests for information from Executives, Directors and other staff regarding claims.
• Remains updated on state and federal healthcare environment, identifying impacts to CalOptima programs and claims processes (utilizing Med Learns, CMS Updates, Medi-Cal Provider Bulletins, Medi-Cal manuals, ICE).
• Reviews ad-hoc analysis and generates reports as requested.
• Collaborates with Project Analysts (Process Improvement) and Training Coordinator to identify process improvement opportunities.
• Partners with trainer and claims management team to create or update document processes and procedures.
• Serves as subject matter expert with end-to-end claims adjudication/processing.
• Facilitates communication on claims related topics.
• Other projects and duties as assigned.
• Create business user test scenarios and testing schedules, including time estimates and deadlines, monitor milestone completion, track all phases of testing and provide timely reporting of issues that impact the testing progress. This includes documenting, prioritizing and tracking changes on the testing documents.
• Manage timelines and priorities and provide professional support to managers and staff.
• Develop policies and procedures; understand and interpret policies, procedures and regulations based on regulatory updates or organizational changes.
• Work with claims data, manipulate spreadsheets, and perform quantitative analysis.
• Identify issues, develop solutions, and prepare recommendations including policies and
• Communicate clearly and concisely, both verbally and in writing, including public presentations.
• Collect data, identify pertinent information, and prepare reports and presentations.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Experience & Education:
• Bachelor’s degree in Business Administration or Management, and/or relevant experience in Health Care or Claims Administration required.
• 2 years of both Medicare and Medi-Cal billing and claims adjudication experience required, including experience with CPT-4, HCPC coding, and ICD-10.
• Proficient in Excel (Advanced), Word, Access, PowerPoint, and experience in full adjudication claims processing systems required.
• Medical Terminology, Claims, Managed Care Benefits and Adjudication.
• Benefits of Medi-Cal and Medicare.
• Policies, services, and general responsibilities and requirements/regulations of claims processing and administration.