POSITION PURPOSE To research and resolve complex claims issues which cross interdepartmental lines and communicate the outcome to the providers and affected PHC managers. To develop and maintain provider training materials for all lines of business and related provider newsletter articles. Conduct provider trainings across PHC departmental lines in group or individual provider settings. ESSENTIAL DUTIES AND RESPONSIBILITIES - Develop provider educational/training materials for all PHC lines of business as related to authorizations, e-systems, claims, eligibility.- Conduct provider trainings in group or individual provider settings which include but are not limited to: claims, authorization, eligibility, or a multiple program overview.- Coordinate with Claims, Member Services, Health Services departments, the development and maintenance of ongoing educational materials and tips for inclusion on the PHC website. Where appropriate incorporate educational materials into the PR Manual and update on a quarterly basis.- Create PR newsletter articles related to issues identified during provider training and research. Coordinate with Claims, Health Services, and Member Services departments.- Review, research, and resolve complex provider inquiries, appeals, and grievances. Assist Provider Relation Representatives with provider billing/authorization issues that require extensive research and coordination.- Track complaints, appeals, and grievances by program. Report activities on a quarterly basis to IQI, the PHC Compliance Coordinator and Claims Director.- Review monthly reports and track claims trends for provider educational opportunities. Present Manager and Director with findings and recommendations for ongoing, long term resolutions to issues. Identify items to address the "provider hassle factor."- Act as liaison and meet with designated staff from Claims, Health Services, Member Services, QI departments to identify ongoing provider issues. Develop provider specific training based on feedback from the departments.- Attend quarterly interdepartmental communication workgroup meetings which include Provider Relations, Claims, Health Services and Member Service staff.- Coordinate system issues with Claims Configuration staff, IT staff and PR Lead Project Specialist/Auditor. SECONDARY DUTIES AND RESPONSIBILITIES - Leads or participates in special projects as needed.- Other duties as assigned. HIRING CRITERIA Education and Experience College course work preferred; minimum three (3) years experience in a claims environment; or equivalent combination of education and experience. Special Skills, Licenses and Certifications Familiarity with AMISYS or similar system. Understanding of claims processing requirements and ability to research claims issues. Ability to use word processing and spreadsheet software effectively. 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 Ability to analyze and research claims issues. Excellent written and oral communication skills. Ability to present statistical and technical data in a clear and understandable manner. Good organization skills. Ability to work on multiple assignments simultaneously, prioritize work and complete projects within established timeframes. Use good judgment in making decisions within scope of authority and handle sensitive issues with tact and diplomacy. Work Environment And Physical Demands Ability to use a computer keyboard. More than 70% of work time is spent in front of a computer monitor. Ability to lift 10 lbs.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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