Claims Research Specialist - SHP Finance - Remote / Hybrid - Day Shift - Full Time

Hours:

Shift Start Time:

7:30 AM

Shift End Time:

4 PM

AWS Hours Requirement:

8/40 - 8 Hour Shift

Additional Shift Information:

Start time 7:30-9:00 end 4:00-5:30

Weekend Requirements:

As Needed

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$30.370 - $37.950 - $42.510

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

This is a full-time position - primarily remote work / work from home. Employees must reside in the state of California for this remote position.

What You Will Do

Responsible for researching and resolving complex inquiries and issues related to billing, provider claims adjudication, and payment disputes. Makes timely correction to errors for increased provider and customer satisfaction. Provides education and detailed first level education to providers about their contract, as well as identifying and notifying provider when an error has occurred. Tracks and trends issues, and makes recommendations for improved contract terms, contract set-up, or claims adjudication policies.

Required Qualifications

• Minimum of 2 years experience in a health plan or other health care setting specifically including claims processing, customer service call center, or provider contracting and relations and medical billing.
• Experience with resolving issues under sometimes tense and stressful circumstances.
• Experience with electronic mail, word processing, spreadsheets, and database programs.

Preferred Qualifications

• H.S. Diploma or Equivalent
• Experience with Managed Care application.
• Certified Procedural Coder - Hospital (CPC-H) - American Academy of Professional Coders (AAPC) -PREFERRED
• Certified Procedural Coder - Payer (CPC-P) - American Academy of Professional Coders (AAPC) -PREFERRED
• Certified Professional Coder (CPC) - AAPC -PREFERRED
• Certified Coding Specialist (CCS) - The American Health Information Management Association (AHIMA) -PREFERRED

Other Qualification Requirements

• Certification in medical terminology and/or medical billing/coding preferred.

Essential Functions

• Claims research

With limited supervision, researches and resolves complex issues related to claims processing and payment in a timely manner and in accordance with established departmental guidelines. Responds to inquiries and requests for assistance from Plan providers and internal departments received via phone, mail, or fax.

Researches and resolves provider payment disputes and appeals.

Makes inquiries regarding claim status.

Explains contract status, financial risk, and payment methodologies.

Communicates clearly with internal and external customers via telephone, email or written communications. Including Claims Department (SDHA) Customer Service, Appeals, Provider Contracting, Health Services and Enrollment.

• Conducts rate negotiations

Conducts one-time negotiations referred from claims department. Documents results and forwards claims for timely payment to claims department.

• Customer service

Provides prompt, accurate and excellent services to internal and external customers.

Develops solid professional working relationships with various internal departments and units and, as required, vendors, providers, employers, brokers and/or other customers.

• General support

Participates in special projects and other duties as assigned. These may include, but are not limited to, work groups, proposals, audits and back-up support for other departments.

Assists in preparation of reinsurance filings.

• Resource management

Maintains an organized work area, paper and electronic files, tools, resources, reference materials required to meet departmental needs. Effectively utilizes resources including, but not limited to:

Plan medical policies and procedures.

All combined Evidence of Coverage (EOC) and Employer Group Benefit Agreements.

DMHC, DHS and CMS regulations, provider manuals, and fee schedules.

Coordination of benefits and third party liability.

Cactus provider database and contracting status checklists.

IDX Managed Care Application.

Operational policies and procedures.

Provider contracts and service agreements.

Word processing and spreadsheet applications.

Knowledge, Skills, and Abilities

• Thorough understanding of managed care principles, models, and reimbursement methodologies.
• Familiarity with DMHC and DHS regulations.
• Familiarity with CPT, ICD-10-CM diagnoses and procedures codes as well as any other billing guidelines.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class