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 the Alameda Alliance for Health and Anthem Blue Cross. In order 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
Reports To: Claims Supervisor
Status: Full-Time (Regular)
The Level I Claims Examiner will be responsible for the examining of all categories of claims, including specialty, ER/UC, PCP and clinic/Capitation claims for both manually and electronically entered claims.
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 examining all types of specialty & clinic/capitation claims based on a comprehensive knowledge of benefit package, utilization guidelines and appropriate division of financial responsibility.
- Support the Supervisor in various Health Plan audit reporting.
- Assist the Claims Supervisor in the training and mentorship of new claims department staff for the processing of claims.
- Assist with health plan claims audit preparations. Also provide support for coding and provider dispute review.
- Perform EZCAP testing on new plan benefits and system enhancements
- Provide shadowing opportunities for employees from other departments on claims examination.
- Contact provider office for additional information on claims inquiries, and resolve issues.
- Participate in updating Policy & Procedures for Claims Department
- Process check run reports as assigned
- Assist with customer care inquires
- Perform other duties as assigned
- Comprehensive knowledge of PCP, Capitation, 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-9 & ICD-10 coding.
- 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.
Minimum of two to four years demonstrated experience in medical claims processing.
CERTIFICATES AND/OR LICENSES
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.