Claims Examiner I

Job Description Organizational Description The Community Health Center Network (CHCN), sister organization to the Alameda Health Consortium, is made up of the eight federally qualified community health centers in Alameda County. CHCN functions as the managed care MSO for our health centers, contracting with Alameda Alliance for Health. To help our health centers meet their missions of providing the best possible care to their communities, we also provide a broad range of training, technical assistance, quality improvement, information technology, and data analytic services. Position Title: Claims Examiner I Department: Claims Reports To: Claims Manager Classification: Non-Exempt Status: Full-Time Regular POSITION SUMMARY The Claims Examiner I is responsible for reviewing and processing all categories of claims; specialty, ancillary, and ER/UC for both manually and electronically entered claims and may include ensuring compliance with Medi-Cal guidelines. ESSENTIAL POSITION RESULTS The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may perform other duties as assigned. Responsible for processing/examination of claims as assigned based on a comprehensive knowledge of benefit package, utilization guidelines and appropriate division of financial responsibility. Work with Certified Coder and/or Manager on claims requiring further examination for coding or medical reviews. Assist with Customer Care claims related inquiries. Contact provider office for additional information on claims inquiries and resolve issues. Verify and validate rejected claims log in preparation for daily provider notifications. Maintain claims email inbox; monitor, entering the claims forwarding faxes to proper parties. Perform EZCAP testing on new plan benefits and system enhancements when needed. Assist with compiling documentation for audits. Review and reconcile DocuStream daily audits. Review check run examiner reports. Responsible for adhering to all CHCN policies and procedures. Perform other duties as assigned and needed. HIPAA Designated Access "For the purposes of the job duties of this position, the person in this position requires access only to the following HIPAA protected information data sets."

1. MSO Membership
2. MSO Claims
3. MSO Referral/Auth.
4. MSO Capitation
5. Data Warehouse
6. Chart Audit/QI
7. Disease Registry

SUPERVISORY RESPONSIBILITIES None MINIMUM QUALIFICATIONS Competencies Basic knowledge of PCP, Specialty, Ancillary, ER and Facility claims processing in an IPA/HMO setting Excellent written and verbal communication skills, to allow for effective communication at any level. Competent in CPT and ICD-10 coding. Strong attention to detail. Organized and self-directed person with the desire to learn and the ability to work well with others. Ability to prioritize and manage multiple projects and maintain deadlines Essential Requirements Minimum of 1-2 years of demonstrated experience in Healthcare IPA/MSO/health plan setting. Minimum of 1- 2 years demonstrated experience in medical claims processing a plus. CERTIFICATES AND/OR LICENSES None PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus. WORKING CONDITIONS AND ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly exposed to an inside/outside environment. The Community Health Center Network is an Equal Opportunity Employer. #J-18808-Ljbffr 6AM City, LLC