Under the direction of the Cost Avoidance Supervisor, the Cost Avoidance Specialist I monitors activities related to cost savings and recoveries of medical claim payments; identifies and verifies members other health coverage (OHI), updates system and recovers overpayment, and researches and validates provider refund checks. The Cost Avoidance Specialist interfaces with all departments in an information sharing capacity to promote proper payment procedures and timely cost effectiveness in claims payments.
Researches and validates all provider refund checks received with duties including but not limited to:
SECONDARY DUTIES AND RESPONSIBILITIES
Other Duties as Assigned
Education and Experience | High School Diploma or equivalent and minimum two (2) years’ experience in health care including experience in processing claim in an automated claims environment, working knowledge of medical terminology, and related procedure and diagnostic coding (CPT-4, ICD-9, ICD-10, HCPCS); or equivalent combination of education and experience. Experience in Medi-Cal operations, Amysis, COB, Reinsurance, and claims billing procedures preferred.
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Special Skills, Licenses and Certifications | Ability to accurately and efficiently perform 10-key by touch required and working knowledge of windows-based PC applications including word processing, spreadsheets, and database management; ability to use MS Word and Excel required. Must possess excellent organizational skills and excellent problem solving skills. Must be proficient in math skills. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
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Performance Based Competencies | Working knowledge of Medi-Cal billing requirements preferred. Working knowledge of claims procedures in a health-based system. Ability to interpret and analyze Explanation of Benefit forms related to primary health insurance policies. Working knowledge of claim types including but not limited to inpatient, outpatient, cross over, FFS, ER, RX, CCS FQHC, DME, and LTC/Hospice. Working knowledge of Medicare billing requirements preferred. Working knowledge of medical terminology. Ability to design and produce reports from database reporting tool (Discoverer preferred). Ability to format and produce professional business correspondence. Ability to process all claims types comprehensively, accurately, and efficiently. Ability to communicate effectively, both orally and in writing. Ability to accurately complete tasks within established time frames. Must have high level of accuracy in detail oriented tasks. Ability to effectively prioritize multiple tasks and deadlines. Ability to maintain confidentiality. Must have the ability to assume responsibility and exercise good judgment in making decisions within the scope of authority of the position.
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Work Environment And Physical Demands | Must have the ability to establish and maintain effective and cooperative working relationships with PHC staff and others contacted in the course of work. Ability to use a computer keyboard. Working knowledge of and ability to operate general office equipment including computer, telephone, photocopy machine, fax machine, etc. Ability to spend more than 70% of work time in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up to 10 lbs.
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All HealthPlan employees are expected to:
HIRING RANGE:
$77,430.47 - $96,788.08
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
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