Hours:
Shift Start Time:
8 AM
Shift End Time:
4:30 PM
AWS Hours Requirement:
8/40 - 8 Hour Shift
Additional Shift Information:
Weekend Requirements:
No Weekends
On-Call Required:
No
Hourly Pay Range (Minimum - Midpoint - Maximum):
$30.370 - $37.950 - $42.510
The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.
What You Will Do
Responsible for investigating and resolving complex health plan issues such as appeals, grievances, and claims resolution related to member and provider disputes. Provides timely response to the health plan issue. Forwards claim issue to appropriate unit for rework if necessary and documents all actions in dedicated file on the common drive. Tracks and trends issues and makes recommendations for improved contract set-up or claims adjudications policies. Interacts with various internal and external departments (Claims Dept; Contracts, Customer Service, Utilization Management, Appeals and Grievance Units of SRS,SCMG, SHP and all health plan liaisons (Health Net; CIGNA; Anthem Blue Cross, Blue Shield, Aetna, United Health Care, Health Net Seniority and Secure Horizons), and additional duties as assigned. The Analyst will serve as a role model in over all conduct, knowledge, expertise and compliance with policies, procedures and safety regulations as defined by Sharp HealthCare.
Required Qualifications
- H.S. Diploma or Equivalent
- 15 Or More Years experience as a Claims Examiner in the insurance industry.
- 3 Years experience with supervisory responsibilities in a managed care environment, and demonstrated self-motivational abilities.
Preferred Qualifications
- Associate's Degree
- Other : Evidence of completion of Medical Terminology class.
Essential Functions
- Claim process tracking
Distributes priority processing to appropriate unit.
Completes Error Tracking Log accurately and timely.
Confirms accurate and timely completion of distributed work.
Reports any issues to management and originating department. - Claims processing
Performs high level and complex work assignments.
Handles specialized claims functions (Molecular claims, time sensitive member reimbursements issues with contracted providers. Work in conjunction with the training unit on release and of high dollar claim. Solely responsible for processing SRS LOA claims received from SRS/SHC Finance. - Problem resolution
Seek to understand and address customers' needs, partner to provide workable solutions.
Tracks and responds to health plan appeals, grievances, claims resolutions and 10 day letters.
Researches and resolves complex issues related to claims processing and payment in a timely manner and within established department guidelines. Responds to inquiries and requests from health plan providers and internal departments received via phone, email or fax.
Researches and resolves provider payment disputes and appeals.
Explains contract status, financial risk and payment methodologies. - Teamwork
Ability and knowledge in all unit functions to assist with the completion of time sensitive work. Will support staff needs due to expected/unexpected absences of supervisors or staff.
Provide unit personnel with training, direction, communication and leadership for the purpose of ensuring complete, accurate and professional performance.
Assist in creating an environment that promotes teamwork, professionalism, competence and communication.
Ensure all regulatory requirements met (state and federal).
Participates in achieving departmental goals. Works in the spirit of cooperation with all employees of Sharp.
Accepts and/or participates in special projects as requested. Completes special projects as needed. - Transplant claims
Receives and review transplant packets to insure all necessary information has been submitted.
Reviews packet against DOFR, authorization and transplant grid for appropriate financial risk at contracted or agreed rate.
Completes individual transplant worksheet listing all claims and payment requirements.
Reviews claim system for potential duplicate claim or adjustments.
Coordinates all of the above to avoid back end recovery. - MSP (Medicare as Secondary Payer) Claims
Knowledge of health plan and medical group operations.
Works with seven health plans for two medical groups (Sharp Community Medical Group and Sharp Rees-Stealy Medical Group).
Reviews MSP packet to coordinate reimbursement to Medicare. Includes working with other departments within Sharp HealthCare including but not limited to Institutional Care Division and Community Care Division.
Communicates with/responds to the Department Of the Treasury of the United States as necessary.
Knowledge, Skills, and Abilities
- Excellent organizational and time management skills, ability to multitask.
- Excellent analytical and problem-solving skills.
- Proficient in medical terminology and use of ICD-9, CPT, HCPC coding systems.
- Excellent verbal and written communication skills.
- Ability to read, speak and hear English clearly. Proficient in Excel, Word and Microsoft Office.
- Ability to work independently in research and decision making with minimal direction from higher level staff.
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class