EEO-1: Administrative Support Worker
POSITION SUMMARY
Ensures compliance with regulatory requirements for provider dispute matters by investigating and resolving a range of provider claim appeals and requests for adjustments. Addresses provider disputes, based on CHGs protocols and regulatory requirements.
COMPLIANCE WITH REGULATIONS
Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and Medi-Cal.
RESPONSIBILITIES
- Investigates and resolves provider claim appeals and requests for adjustment for all product lines by evaluating documentation provided by the appellant, identifying if initial claim was paid in accordance with terms and conditions of provider contract or established reimbursement guidelines, adhering to contractual requirements established by regulatory agencies, interpreting policies and procedures from other internal departments (Claims, Health Care services, and Member Services), meeting all requirements specified on Provider Dispute Resolution policy and procedure, making claim appeal determination (payment, reduction, or denial) based on circumstances identified through case research and investigation, and documenting relevant facts related to the case on the internal Provider Dispute Module and QNXT.
- Conducts thorough the review of provider disputes in presenting recommendations.
- Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.
EDUCATION
- High school diploma or equivalent training.
- Bachelors Degree preferred.
EXPERIENCE/SKILLS
- Five years of experience involving dispute resolution and claims adjudication.
- Strong knowledge of AB1455 regulatory requirements
- Knowledge of CPT and ICD10 coding, and medical terminology.
- Knowledge of claims dispute determination and resolution procedures and coding practices.
- Ability to read, analyze and interpret regulations and contract language.
- Excellent customer service skills.
- Good technical writing skills.
- Good judgment and problem solving skills; team player; and ability to work independently.
PHYSICAL REQUIREMENTS
- Prolonged periods of sitting and frequent walking.
- May be required to work evenings and weekends.
The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.
All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.