Claims Recovery Specialist

Job Details

Description

Who We Are

Pacific Clinics is California's largest community-based nonprofit provider of behavioral and mental health services and support. Our team of more than 2,000 employees speak 22 languages and are dedicated to offering hope and unlocking the full potential of individuals and families through culturally responsive, trauma-informed, research-based services for individuals and families from birth to older adults.

Who We Serve

Pacific Clinics serves children, transitional age youth, families, adults, and older adults. We offer a full range of mental and behavioral health services, foster care and social services, housing, continuing adult education and early childhood education programs to Medi-Cal eligible individuals and families throughout Alameda, Contra Costa, Fresno, Kings, Los Angeles, Madera, Orange, Placer, Riverside, Sacramento, San Bernardino, San Francisco, Santa Clara, Solano, Stanislaus, Stockton, Tulare and Ventura Counties.

Compensation We Offer

• The initial compensation for this position ranges from $21.00 - $25.83 per hour.
• Salary is dependent on commensurate experience above the minimum qualifications for the role and internal equity considerations.
• The salary may also vary if you reside in a different location than the location posted.
• 7.5% Bilingual Differential for qualified positions*
• * Must meet company policy eligibility requirements.
  

Benefits We Offer

• Benefits eligibility starts on day ONE!
• We Offer Comprehensive Medical, Dental & Vision benefits, Voluntary Life Insurance, Flex Spending, Health Savings Account, EAP, and more!
• Employer Paid Long-Term Disability & Basic Life Insurance
• 401K Employer Match up to 3.5%
• Competitive Time Off Plans (may vary by employment status)
• Employee engagement and advocacy opportunities to advance our justice, equity, diversity, and inclusion agenda across our Agency and throughout the communities we serve.
  
  
  

About Our Program

Claims Operations

Program Type: Administration

Position Summary

Primary responsibilities are to monitor, analyze, correct, and resubmit to healthcare payors, all claims that have been denied by payors preventing successful adjudication of these claims. Responsibilities also include verification of clients’ healthcare benefits and eligibility to determine the correct payor waterfall sequence for claim resubmission. The Claims Recovery Specialist will transfer claims to the next payor in the waterfall sequence as necessary for successful claim adjudication. All steps require use of electronic systems to analyze, correct and submit claims, as well as for eligibility verification, with some carrier phone contact necessary. When claims cannot be processed further, the specialist will use the Welligent Electronic health record system (EHRS) to adjust off the balance, strictly adhering to agency policies on such matters.

Essential Duties And Responsibilities

• Monitor, analyze, correct, and resubmit to healthcare payors in a timely fashion, all claims that have been denied by payors preventing successful adjudication of these claims, which entails:
• Research and resolve denied claims, adjusting client payor information as necessary.
• Review client eligibility verification results / reports and take appropriate follow-up action to ensure the correct payor is billed when resubmitting claim, this may include working with the Client Data Admin department to follow-up with the clinical provider, changing the client’s payor waterfall set-up in the EHRS, etc.
• Assist in establishing and implementing appropriate provider involvement together with Client Data Administration department as necessary to resolve claim denials.
• Retrieve and review claim denial reports and complete the required steps to document actions taken by the due date for each report, such as the State Denial report, and the Weekly Claims Denial report.
• Monitor “void claim” as a result of denials or eligibility changes, to ensure proper procedures and processes are followed.
• Ensure proper documentation and record of each claim related action, for example, enter the reason of voiding or transferring a claim in the “Collection” tab, or explain the reason a pay source set is being changed in the pay source “Note” area, etc.
• Follow written procedures regarding eligibility changes and related matters.
• Ensure appropriate corrective actions have been completed prior to the next EHRS processing day and/or interject when repetitive errors occur or have not been corrected.
• Consult with Director of Client Data Administration and/or Program Team Supervisors and Program Directors regarding recurring issues and escalate resolution to supervisor, Division and Corporate management as needed.
• Review, track, monitor and verify all void requests for accuracy and applicability per Agency guidelines including obtaining appropriate authorization to void billing and ensuring voided billing is completed in the DMH data system.
• Monitor, analyze, correct, and submit to healthcare payors in a timely fashion, all claims that have been delayed due to errors, such as are categorized in EHRS as violations, unbilled services, and ungathered services, which entails:
• Retrieving and reviewing claim error reports and completing the required steps to document actions taken by the due date for each report, such as the Monthly Eligibility Report, Weekly Unbilled Report, Weekly Invalid Claim report.
• Ensure the accuracy of all data fields and pay source setup/changes during the error correction process.
• Follow written procedures regarding errors and the corrective action of errors, including but not limited to: Welligent Violations and Unbilled Services Report, Invalid
  
  
  

Claims Report, Local Denials (IS Rejections) Report, State Denials Report, etc.

• Independently monitor, analyze, identify, report, categorize, and investigate claim denial patterns and trends, in order to assist the agency to continuously improve / reduce the denial rates (as a % of claims submitted), working with providers, Client Data Admin department and/or appropriate team members to improve these rates.
• Complete client eligibility change tasks reflected by the Eligibility Reports (weekly and monthly) to ensure eligibility changes are reflected in EHRS client paysources as soon as eligibility changes have been verified through the Medi-Cal Eligibility website.
• Attend job related meetings and trainings.
• Attend and participate in department activities and staff meetings, providing clear and useful input on department procedures and targets.
• Provide backup support within the team when requested.
• Follow HIPAA policies.
• Perform all duties and work projects as assigned.
• Report to work on time and maintain reliable and regular attendance.
• Willing to work overtime during the weekdays and weekends (Saturday and/or Sunday) when requested.
• Communicates effectively in a culturally competent and diverse consumer population and promotes favorable interaction with managers, co-workers and others.
• Initiate and maintain professional interactions and communication with Clinics’ employees and/or others.
• Participate as part of a multidisciplinary team and interacts with all levels of organizational staff and management; outside auditors and/or Agency vendors.
• Maintain professional and effective working relationships, following all policies and procedures and approaching challenges with a proactive and positive attitude. Develop strong, trusted relationships with colleagues and customers.
• Maintain the confidentiality of all business documents and correspondence.
• Model Pacific Clinics’ approach, mission, and core values in all communication and correspondence.
• Participate as part of a multicultural team, being sensitive to the cultural and linguistic needs of the clients and families served.
  
  
  

Experience / Requirements

Knowledge, Skill and Ability Requirements:

• Knowledge of the healthcare service claiming workflow, preferably in Behavioral Healthcare using the Welligent EHRS
• Familiar with the healthcare claim payors, and the payor waterfall, including third party payors; preferably in Behavioral Healthcare
• Prefer knowledge of an Electronic Health Record System (EHRS) used in Healthcare for billing clinical services; preferably in Behavioral Healthcare
• Knowledge of the Healthcare Taxonomy / NPI structure and codes.
• Ability to use the Windows file system, as well as Microsoft Word, Outlook, Access, and Excel applications with moderate to intermediate proficiency.
• Skilled in speedy and accurate computer data entry with the ability to use a computer keyboard proficiently, above 35 wpm.
• Skilled in making decisions and using good judgment, dealing with ambiguity and change, and producing high quality work.
• Skilled in deductive reasoning, data analysis, problem solving, multi-tasking, completing repetitive tasks with accuracy, and improvising with a creative approach to problems and obstacles
• Skilled in being very detail and results oriented, approaching tasks methodically, following through on projects to achieve results, being organized and prioritizing competing deliverables.
• Skilled in customer service.
• Skilled in professional verbal & written communication.
• Ability to prioritize extremely time sensitive document submission; must be flexible, organized, and conscious of these timelines
• Ability to communicate effectively with a competent and diverse population and promote favorable interaction with managers, co-workers and others
• Ability to adapt and be flexible in a rapidly changing environment, be patient, accountable, proactive, take initiative and be a Team player and work effectively on a team
• Ability and willingness to learn new topics, systems, and methods
• Ability to independently problem solve as well as analyze and resolve complex issues related to billing issues
• Ability to work with minimal supervision Education and Experience Requirements
• Minimum of a High School Diploma or G.E.D with (3) three years direct healthcare billing experience.
• Two years previous data entry work experience in healthcare EHRS billing.
• Typing 35 wpm with accuracy required.
• Other Health Coverage (OHC) billing experience and Medicare billing experience referred.
• Must possess a valid California driver's license and maintain an insurable driving record under the clinics' liability policy (if driving two or more times per week on company business) OR if driving is not required, demonstrated ability to use public transportation or other means to travel between sites, if requested.
  
  
  

Physical Requirements

While performing the duties of this job the employee is frequently required to stand or sit. The employee is required to use hands to produce records and/or documentation in manual or electronic format. The employee must regularly lift and/or move up to 5 pounds and occasionally move or lift up to 10 pounds.

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.

Equal Opportunity Employer

We will consider for employment qualified Applicants with Criminal Histories in a manner consistent with ordinance 184652 Sec.189.04 (a) and San Francisco Police Code, Article 49. Section 4905.