WHY CALOPTIMA?
CalOptima is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health. If you’re looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima.
JOB SUMMARY
Under general direction of the Supervisor, the Claims Lead oversees the activities of the Claims Resolution Provider Disputes (PDR) team members. The incumbent monitors PDR inventory volume and provides subject matter expert training. The incumbent provides phone processing guidance and direction to the Claims Resolution Specialists when handling complex or escalated provider disputes.
POSITION RESPONSIBILITIES:
- Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
- Provides technical and/or process direction to the provider dispute team and ensure provider disputes are completed within the department/regulatory performance guidelines.
- Monitors PDR volume for staff and works with Supervisor/Manager to adjust as needed; works with Supervisor/Manager to assign PDR coverage around absences and other scheduling conflicts.
- Identifies and advises management team of trends, problems and issues identified, as well as recommends courses of action. Informs management of new procedures and ideas for continuous process improvement and coordinate with the department Trainer, Business System Analyst, and Process Improvement Coordinator.
- Compiles, reviews and analyzes management reports and take appropriate action.
- Performs periodic quality review on PDRs in compliance with audit requirements and quality standards.
- Acts as the subject matter expert for complex provider issues.
- Adheres to all policies and procedures.
- Ensures team achieves results, meets goals, and follows up promptly on action items and requests.
- Tracks the productivity and quality of team members.
- Informs Supervisor/Manager of department progress.
- Assists staff by addressing technical questions.
- May assist Supervisor/Manager with interviews.
- Provides input regarding Resolution Specialists performance criteria.
- Ensures staff follows procedures and instructions to promote accuracy and quality outcomes.
- Handles escalated PDR issues before forwarding problems to Supervisor/Manager.
- Represents Supervisor/Manager at meetings in absence of that leader when appropriate.
- Provides input to Supervisor/Manager regarding skill level of each individual on the team.
- Serves as project and/or system testing support for the department as needed.
- Supports the department with process implementation, improvement projects, training and quality audit as needed.
- Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
- Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.
- Completes other projects and duties as assigned.
POSSESSES THE ABILITY TO:
- Demonstrate professional behavior, good business judgment and strong team interaction skills.
- Establish and maintain effective working relationships with CalOptima Health’s leadership and staff.
- Diffuse emotional situations with internal and/or external customers.
- Influence others using a positive approach.
- Communicate clearly and concisely, both orally and in writing.
- Troubleshoot technical problem areas.
- Encourage and utilize suggestions and new ideas.
- Manage and keep track of multiple tasks.
- Remain objective when dealing with emotional topics or when having to give feedback to peers.
- Work in a team environment.
- Meet or exceed performance competencies.
- Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
EXPERIENCE & EDUCATION:
- High School diploma or equivalent required.
- 3 years of related claims processing experience required.
- An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
PREFERRED QUALIFICATIONS:
- Associate degree or Bachelor’s degree in Health Care Management or related field preferred.
- Team leadership role in a managed care environment preferred.
- Previous experience in directing the work of others (i.e. training, responding to questions, etc.) preferred.
- Experience in a Managed Care environment preferred.
KNOWLEDGE OF:
- Medical claims administration/processing, including medical terminology, Revenue, CPT, ICD-9 and HCPCS codes.
- Claims management processes, industry pricing methodologies, such as RBRVS, Medicare/Medi-Cal Fee Schedules and etc.
- Medi-Cal and and/or Medicare program guidelines.
- Relevant business practices and applicable regulations/policies.
- Benefit interpretation and administration.
- Department reports, their purpose and how to interpret them.
DEPARTMENT(S): Customer Service
REPORTS TO: Supervisor, Claims
FLSA STATUS: Non-Exempt
SALARY GRADE: G - $26.44 - $37.55 ($55,000 - $78,100)
CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
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If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.
Required Skills
Required Experience