DEPARTMENT(S):  Claims Administration REPORTS TO:  Supervisor, Claims (Medi-Cal) FLSA STATUS:  Non-Exempt SALARY GRADE:  C - $19.7115 - $25.4808 ($41,000 - $53,000)

JOB SUMMARY

This position is responsible for analyzing and validating claim data elements and claims processing.  The incumbent is responsible for adhering to the regulatory and internal processing guidelines in conjunction with CalOptima policies and procedures related to claims adjudication.

POSITION RESPONSIBILITIES:

• Performs thorough review of pended claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services.
• Processes non-institutional claim types.
• Corrects system generated errors manually prior to final claims adjudication.
• Processes claims based upon CalOptima contractual agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and CalOptima policies and procedures.
• Analyzes and validates Medi-Cal pricing; researches, adjusts and adjudicates claims; reviews services for accurate charges and utilizes current billing code sets, i.e. International Classification Diseases (ICD10) codes, Current Procedural Terminology (CPT) codes and/or authorization guidelines as reference.
• Validates eligibility and other possible health insurance coverage on the claim.
• Alerts manager or supervisor of more complex issues that arise.
• Processes claim exception reports as assigned.
• Other duties as assigned by management.

POSSESSES THE ABILITY TO:

• Meet and maintain established quality and production standards.
• Work independently and as part of a team while providing excellent customer service skills.
• Develop and maintain effective working relationships with all levels of staff and providers.
• Handle multiple tasks and meet deadlines.
• Communicate clearly and concisely, both verbally and in writing.
• Utilize and access computer and appropriate software (e.g. Microsoft Office; Word, Excel, PowerPoint) and job-specific systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

EXPERIENCE & EDUCATION:

• High School diploma or equivalent required.
• 1+ year of experience processing on-line medical claims in a managed care or PPO/indemnity environment or billing environment and/or equivalent billing and customer service related experience in a claims processing unit required.

PREFERRED QUALIFICATIONS:

• Experience processing Medi-Cal claims preferred.

KNOWLEDGE OF:

• Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPC) and ICD-10 codes.
• Industry pricing methodologies, such as Resource-based Relative Value Scale, Medicare/Medi-Cal Fee Schedule, etc.
• Medical terminology; benefit interpretation and administration.
• Facets Processing System preferred or equivalent system.
• Medi-Cal guidelines and regulations.

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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Required Skills Required Experience

• Possess creative talent in conceptual design and rendering skills of either hand or computer sketching.
• Advanced knowledge of design principles and the ability to interpret design concepts and layouts, including commonly used concepts, practices, and procedures within the profession.
• Knowledge of design, trends, construction methodology, materials application and manufacturer-supplier appropriateness.
• Advanced knowledge of furniture, fixture and equipment (FF&E), architectural/interior finishes, lighting, signage, art, and color schemes to carryout design intent.
• Knowledge of building regulations and safety codes.
• Knowledge of design techniques, tools, and principles involved in production of precision technical plans, blueprints, drawings, and models.
• Thorough knowledge of sustainability, integrated design and LEED guidelines.
• Knowledge of buildingSMART, Building Information Modeling (BIM) and Integrated Project Delivery (IPD).
• Proven ability to prioritize in order to meet deadlines and provide high quality service to clients.
• Proficiency in the basic technical skills of interior design including the following computer skills:
• Proficiency in MS Office, including Word, Excel and Outlook.
• Proficiency in Newforma preferred.
• Proficiency in AutoCAD/Architectural Desktop.
• Proficiency in Revit is preferred.
• Knowledge of 3D Modeling software such as 3D Studio Max and Viz 2006.
• Knowledge of Photoshop, Illustrator, Sketchup, and InDesign graphic software.
• Ability to effectively meet deadlines.
• Ability to communicate effectively, both verbally and in writing.
• Ability to work in team environment.