Senior Claims Analyst Lead

Position Summary

Under the direction of the Senior Operation Manager, the Senior Claims Analyst, Lead, is responsible for coordination and oversight of daily claims operations and assisting with the management of the claims inventory and functions. This includes supervising the day-to-day activities and performance of assigned staff, carrying out department goals and objectives, measurements of performance, adherence to policies and procedures, and ensuring performance and work product quality standards are met, and any other duties assigned

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statement(s)

•    Collaboration with internal and external customers to resolve inquiries, resolves moderate – complex claims issues, assist with claim audits and adjustments, acts as an Subject Matter Expert and department resource on claims and system issues.

•    Schedules and conducts various training(s), including new hire, policy and process updates and communicates processing related issues and updates to staff.

•    Assists leadership team with developing and maintaining training materials.

•    Coordination and oversight of daily claims processing operations, and assists with management of the claims inventory 

•    Assisting in the review and analysis of claims inquiries, claims tracers, pended claims, explanation of benefits, batch reports and other reports to resolve specific claims issues

•    Provide oversight for workflow within the assigned area of the Claims Department, to include, but not limited to claims inventory and claims inquiry resolution

•    Maintaining excellent working knowledge of the use of and ability to modify various software tools used in the Claims Department

•    Assisting in the development, installation, testing and management of new software/hardware/networking solutions

•    Responding to elevated/urgent provider issues when necessary

•    Modifying/adjusting claims when necessary; and

•    Carries out department goals and objectives, and procedures and ensures performance and work product quality standards are met 

•    Monitoring, and assuring efficient accurate performance of the claims processing operation, including proper administration of benefit and payment rules, appropriate provider communication via phone and written correspondence and accurate configuration of the claims processing systems

•    Preparing and reviewing quality control audits with staff to ensure compliance within established department guidelines, goals, policies and procedures

•    Producing policy and procedure instructions for the department which includes development, implementation, and interpretation of policy and procedures 

•    Performing analysis and developing improvements to operations

•    Producing and maintaining statistics of claims production and inventory for Sr Operation Manager on a daily, weekly, monthly and adhoc basis

•    Responsible for the Quality Control (QC) process which consist of implementing the quality control process; revising the process as needed, monitoring, tracking, auditing and reporting QC outcomes 

•    Identifying QC issues; and developing and implementing corrective action plans as needed

•    Interacting with all other departments as needed to resolve claims related issues and assist in policy planning and implementation

•    Maintaining current knowledge of GCHP policy and procedure, Medi-Cal, Provider Manuals, Knox Keene, and Title XXII regulations; and

•    Maintaining current versions of the Claims Operating Manual, and other Claims Department related documents such as job descriptions and the Claims Section Provider Manual

•    Leading or participating in special projects and assignments as needed

•    Any other duties assigned

POSITION QUALIFICATIONS

Competency Statement(s)

•    In-depth knowledge of procedure coding and medical terminology, and their application in benefits

•    In-depth knowledge of general medical policy benefits and exclusions

•    Basic knowledge of industry standard payment practices

•    In-depth knowledge of managed care practices related to claims

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