Claims Analyst I, Chula Vista, CA

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Description

Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year.

We know that by serving our employees well, they, in turn, will better serve our nearly 360,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

We are currently recruiting for:

TITLE: Claims Analyst I
Target Hiring Range: $17.85 - $20.53 Per Hour
EEO1: Administrative Support Worker

POSITION SUMMARY

Familiar with Medi-Cal and Medicare benefits, including coordination of benefits. Issues claims payment in accordance with Medi-Cal and Medicare established payment procedures and departmental standards for professional and hospital claims. Must meet or exceed production and quality standards. Ability to interpret documented policies and procedures.

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

• Must be familiar with Medi-Cal and Medicare claims processing guidelines, to adjudicate claims accurately and in a timely manner.
• Reviews each claim edit in sequence and determines appropriate action, based on established protocols and disposition guidelines.
• Processes claims in a timely and accurate manner by meeting or exceeding established quality and production standards, utilizing reference materials; researching exceptional claims; identifying and reporting unique and/or excessive billing practices and/or inconsistencies or concerns, adjusting previously processed claims as instructed by the claims auditor, supervisor or manager.
• Supports the team effort by maintaining department and corporate policies and procedures; enhancing professional growth and development through participation in education programs and reviewing current literature; attending meetings and workshops; performing other duties as assigned or requested.
• Reports and identifies patterns of incorrect system configuration that impact payment. Advises supervisor of items that are unclear or not addressed in established criteria/payment guidelines.
• 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.
• Ability to follow written directions, including interpretation of desktop procedures and payment guidelines.

Qualifications

Education:

• High school diploma.
• Medical terminology or related work experience.

Experience/Skills:

• Two years claim processing experience.
• Managed Care, Medi-Cal and/or Medicare claims processing experience.
• Ability to operate a personal computer, copier, fax machine, telephone.
• Knowledge of CPT, HCPC & ICD-10 Coding.
• Knowledge of standard claim payment policies.
• Strong mathematics, organizational and analytical skills.
• Good verbal / written communication skills.
• Ability to work independently.

Physical Requirements:

• Prolonged periods of sitting; typing and viewing video display terminal.
• May work alone and in confined space.
• May be required to work evenings and/or weekends.

***Must have current authorization to work in the USA***

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action .

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