Reports to: Department Manager
Department: Claims Administration
Calibrated Healthcare Network (CHN) manages over 11 million lives in over 8 states, partnering with industry leaders in the area of managed care. Our operating model features global workforce strategies, coupled with efficient technological solutions. We have a proven expertise in re-engineering complex managed care business processes to provide value to our esteemed partners. Our commitment to the evolution of healthcare is evident in our investment in research and development for the progression of dynamically enhanced technology to meet the needs of partners. The core suite of services includes Claims Adjudication, Benefits Setup, Member Enrollment and Eligibility Setup, Claims System Configuration, HCC Coding and MSO Development support.
The Calibrated Clinical Solution (CCS) global workplace is built on the concept of providing cost-effective care, enhancing population health strategies, and improving the quality of care. Calibrated Clinical Solutions deploys the use of proprietary software to create cost-effective workforce solutions constructed on the premise of collaboration technology. With our extensive domain of knowledge of managed care and dynamically enhanced technology, we have the capacity to create innovative solutions for our managed care and primary practice partners. Our core suite of services includes Medical Management, Utilization Management, Complex Case Management, and Population Health Management.
They will be responsible and accountable to support organizational goals and follow all processes with a focus on Claims Adjudication. This Claims Adjudication role will include reviewing and examining claims based on provider and health plan contractual agreements, claims processing guidelines, coordinating benefits (COB) with other health insurance, reviewing duplicate claims, and manual processing to ensure the accurate and timely processing of all claims. They will work as part of a team to meet Service Level Agreements (SLA’s) in accordance with client contracts, established departmental and governmental guidelines.
- Bachelor’s Degree in Business Administration, Health Care or another related field
- Minimum 2-3 years of experience in US Healthcare that directly aligns with the specific responsibilities for this position
- Well-versed with HMO Plans
- Knowledge of Medi-Cal and Medicare are a plus
- Core Competencies: Ethics and Values, Customer Focus, Action-Oriented, learning on the Fly, Manage/Measure Work, Drive for Results, Priority Setting, Timely Decision-Making, Organizing, Functional and Technical Skills
- Computer Proficiency (MS Word, MS Excel)
- Minimum typing speed 40 WPM
- Strong communication skills (English verbal and written), and technical skills to use for Claims processing
- Must have a thorough understanding of claims operations, including, but not limited to, prior roles as adjuster/examiner, claims operations, or equivalent
Essential Functions of Job
- Responsible for following all departmental policies and procedures.
- Receive direction and training on extensive claim adjudication.
- Work and manage claims first in and first out basis.
- Using DOFR-Division of Financial Responsibility – Identify claims that are not our clients financial risk.
- Verify patient’s accounts for eligibility and benefits.
- Read, interpret and summarize provider contracts.
- Validate paper claims data against system data for accurate data capture.
- Adjudicate claims in accordance with department policies and procedures and other business rules.
- Meets production and quality standards as established by Client.
- All other duties as assigned