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Santa Clara Family Health Plan · 2 months ago

Claims Analyst II

San Jose, CA

Full-time

Onsite

Entry, Mid Level

$60K/yr - $87K/yr

2+ years exp

Santa Clara Family Health Plan is seeking a Claims Analyst II to analyze, process, and adjust routine and complex facility and professional claims for payment or denial. This role supports the Claims Department operations while ensuring compliance with Medicare and Medi-Cal regulatory requirements.

CommunitiesHealth CareInsurance

Comp. & Benefits

Responsibilities

Follow established Health Plan policies and procedures and use available resources such as provider contracts, Medicare and/or Medi-Cal guidelines and Member Evidence of Coverage (EOC) to analyze, process and adjust routine and complex assigned claims in an accurate and timely manner

Research, identify, resolve and respond to inquiries from internal Health Plan departments regarding outstanding claims-related issues

Assist Claims Supervisor and Manager with pre-check run reports

Maintain and organize all processes related to Third Party Liability (TPL) claims, including communication of relevant information to appropriate parties

Participate in system testing and communicate newly-identified and potential issues to the Claims Supervisor and Manager and provide recommendations for improvement

Process claims refund checks on a weekly basis to ensure accuracy/completeness of information and submit to the Finance Department in a timely manner

Attend and actively participate in daily, weekly, and monthly departmental meetings, training and coaching sessions

Perform other related duties as required or assigned

Qualification

Claims processing experienceMedi-CalMedicare knowledgeCPTHCPCSICD-10 knowledgeQNXT claims processing softwareComputer software proficiencyJudgmentCommunication skillsWork under pressureConfidentiality

Required

High School Diploma or GED

Minimum two years of claims processing experience in a Health Plan Claims Department

Prior experience with managed care plans, Medi-Cal and/or Medicare programs, and working with underserved populations

Ability to analyze, process and adjust routine and complex assigned claims in an accurate and timely manner

Understanding of professional and hospital reimbursement methodologies, including medical terminology, and working knowledge of CPT, HCPCS, ICD-10, and ICD 9 codes

Understanding of the relationship between the health plans, IPAs, and DOFR

Ability to consistently meet Quality and Productivity Key Performance Indicators by participating in and achieving the Claims Quality standards

Ability to consistently meet Attendance Key Performance Indicator by being punctual and meeting the Claims standards in accordance with the team schedule

Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel

Ability to use a keyboard with moderate speed and a high level of accuracy

Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing

Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes

Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position

Ability to maintain confidentiality

Ability to comply with SCFHP's policies and procedures

Ability to perform the job safely with respect to others, to property, and to individual safety

Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time

Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds

Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less

Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment

Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone

Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail