JOB DESCRIPTION SUMMARY

Qualifications

• High school education or equivalent and minimum of two (2) to five (5) years of experience as a medical/dental claims auditor/investigator and/or medical insurance account management/sales. 
• Basic knowledge of word processing, spreadsheet, presentation media and end-user office software.
• Ability to work under pressure and adapt to a changing environment.
• Knowledge and experience of International Statistical Classification of Diseases and Related Health Problems (ICD-9, ICD-10), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS II & III), coordination of benefits, Medicare, Hospital claims, surgery claims, subrogation, and accident claims.
• Proficient with terminology comprehension.
• Good verbal and written communication skills. 
• Working knowledge of Employee Retirement Income Security Act of 1974, (ERISA) claims processing/adjudication guidelines.
• Exceptional organizational, time management, critical thinking, and problem-solving skills.
• Knowledge of client specific, potential, and aggregate reporting under reinsurance a plus

Duties And Responsibilities

• Gather, organize, and review all necessary claim information required to submit excess loss claims (stop loss claims) to various individual Reinsurance Carriers to insure maximum reimbursement.
• Submit claims, following Carrier Guidelines, based on reports generated after each payment run.
• Respond to internal/external customer inquiries and requests within the department-established timeframe.
• Troubleshoot for potential departmental policy and procedure issues.
• Ensure claims processed within the MEWA, ERISA, and California Department of Insurance standards, as they apply.
• Support clients, carriers and brokers at every step involved in completion of the claim reimbursement process.
• Monitor large case management files with utilization review, eligibility unit and claims examiners.
• Answer inquires related to Advance Funding.

• Prepare and send required monthly specific and aggregate stop loss reports for brokers, carriers, and clients.
• Create special ad hoc report requests.
• Ensure timely responses to customer inquiries and requests for data information.
• Analyze claims data, diagnosis reports and utilization review data to identify potential high dollar claimants. 
• Create potential high dollar report required as monthly distribution to Reinsurance Carriers.
• Prepare and provide last quarter reporting to Account Managers as they prepare for client renewal.
• Identify and notify Account Managers, clients, and brokers of priority claims at year end to insure maximum reimbursement.
• Identify potential ongoing high dollar claimants for disclosure at renewal.

• Monitor the reinsurance process to ensure timely filings occur and year-end process meets client needs.
• Monitor catastrophic health claims for PCMI & WGAT to eliminate the possibility of lost reimbursements.
• Analyze high dollar claims to ensure maximum and prompt reimbursement.
• Meet “Scheduled Adherence” average monthly metrics.
• Meet “Conformance” average monthly metrics.
• Monitor for prompt reimbursement receipt (goal 18 days) of reporting submission documents.
• Audit Carrier response to ensure accurate reimbursement and submit payment appeal if necessary.

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
• All other duties as assigned.

Physical Demands/Work Environment