POSITION PURPOSE To support the designated Claims Supervisor in maintaining claims Long Term Care adjustments and claim recovery activities for all PHC product lines within established guidelines. Participates in interdepartmental adjustment projects. ESSENTIAL DUTIES AND RESPONSIBILITIES - Processes LTC claim adjustment requests for all PHC product lines.- Performs LTC Cash and Statistical adjustments based on retroactive rate changes.- Maintains LTC reports received from the Recovery Specialists and reports completion of these reports back to the Recovery Specialist and the Claims Recovery Supervisor.- Backs up Claims Customer Service Unit on LTC paper or eCIF's as needed.- Performs special claims adjustment projects as assigned.- Maintains current knowledge of PHC Claims Policies and Procedures, State of California Medi-Cal Provider Manual, Title 22, and Medicare guidelines. - Responsible for generation of refund requests related to claims negative balance collection efforts. SECONDARY DUTIES AND RESPONSIBILITIES - Participates in special projects and assignments as needed. HIRING CRITERIA Education and Experience Minimum one (1) year of claims examining experience or PHC claims examining experience and completion of PHC claims training; or equivalent combination of education and experience. College course work in business or related field preferred. Special Skills, Licenses and Certifications Knowledge of Medi-Cal and/or managed care claims processing. Knowledge of CPT, HCPC procedure, and ICD-9 diagnostic coding. Typing speed 30 wpm and proficient use of 10-key calculator. Must be proficient in Microsoft Excel at an intermediate or higher level. Valid California driver's license and proof of current automobile insurance compliant with PHC 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 judgment within scope of authority and handle sensitive issues with tact and diplomacy. Ability to work on multiple tasks within established time frames and sometimes with conflicting priorities. Good organizational 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 90% of the work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up to 10 lbs. Ability to attend off-site meetings as required. All HealthPlan 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 HealthPlan's policies and procedures, as they may from time to time be updated. 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 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.
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