To design, produce, and analyze Claims Department operational data in support of department
objectives and goals. To provide organizational and technical support for the analysis, design,
configuration, and documentation of Partnership’s computer systems, and technical and problem
resolution support to the systems user community. Utilize knowledge of numerous applications,
databases, information systems, statistical tools and analytical principles to monitor and analyze
information related to department operations.

• Creates and runs all reports that are required from retro system configuration updates to identify all impacted claims for Recovery of monies or for adjustments to previously paid claims
• Serve as a liaison for Claims to Configuration, Contracting, and Finance.
• Maintains in-depth knowledge of Partnership systems from a technical and end-user perspective.
• Performs analysis, design, configuration, and testing of assigned systems.
• Uses various resources to troubleshoot and resolve system issues.
• Tests and takes part in implementation of new releases and upgrades.
• Analyzes new systems and functionality and makes recommendations to business users and IT.
• Writes processes and procedures.
• Track all recovered monies through the claims process
• Creates and runs all reports that need to be ran to identify provider trends
• Performs system audits to ensure the system is behaving as expected
• Performs internal audits of all Partnership Provider contracts 90 days post implementation
• Run ad hoc reports as requested
• Prepares monthly summary of System audits
• Prepares quarterly summary of Contract audits
• Monitor health plan policies and procedures and assist with documenting Claims related business requirements and decisions that result from configuration and other change driven sources.
• Participates in system upgrade/update testing as needed
• Develops short and/or long-term resolutions by identifying root causes using reporting and other data files available
• Troubleshoot and perform research on medium to moderately complex claims processing issues and projects.
• Provide recommendations on the design of claim payment system configuration
• Serve all stakeholders through continuous monitoring and auditing of claim processing, educational and problem-solving support
• Maintain regular and consistent contact with operations management, clinical leadership, and appropriate health plan leaders
• Analyze, interpret, and recommend updates to policy and procedures applicable to managed care reimbursement payment methodologies using payment rules and requirements from sources such as CMS, California State Medi-Cal, and DHCS.
• Other duties as assigned.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$37.22 - $46.53

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.