The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.
Work Culture:
GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work – Together.
GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).
GCHP’s focuses on 5 Core Values in the workplace:
• Integrity
• Accountability
• Collaboration
• Trust
• Respect
Disclaimers:
• Flexible work schedule is based on job duties, department, organization, or business need.
• Gold Coast Health Plan will not sponsor applicants for work visas.
POSITION SUMMARY
Under the direction of the Senior Operations Manager, the Operations and Provider Support Analyst III will act as liaison between GCHP and the provider community to effectively resolve provider issues and address concerns and resolve problems telephonically and via email. The Operations and Provider Support Analyst performs a variety of research, and analytics, auditing and resolution activities related to the claims processing and provider function. These activities include, but are not limited to, responding to inquiries related to claim submissions and processed claims, identifying claim errors, root causes and recommended solutions. The OPSA will also respond to inquiries from providers regarding contracts, available in-network services, and billing procedures.
Training occurs: November 18th through January 6th
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 Statements
• Act as a liaison between Gold Coast Health Plan and the provider community to effectively resolve provider issues, address concerns and resolve problems
• Assists in prioritization of provider claims research projects recognizing compliance and business priorities. Communicates to GCHP and BPO leadership all root because errors to assure corrective actions are taken to prevent future problems.
• Creates or updates claim-related policies, procedures, workflows, and job aid manuals
• Create and maintain practices on quality metrics related to provider training
• Recommends appropriate prospective and retrospective auditing processes to assure accurate and compliant processing of claims, disputes and adjustments
• Analyzes claims issues in coordination with designated Claims leadership in accordance with GCHP policies and procedures, regulatory requirements and industry standards for Claims adjudication
• Answers provider service lines as necessary and responds to provider inquiries either by phone or email regarding claims related questions
• Properly documents all calls/contacts as required by department standards in a timely, clear and concise manner using GCHP's internal in person tracking system
• Performs post payment auditing in accordance with GCHP audit programs, policies and procedures, regulatory requirements, and industry standards for Claims adjudication.
• Performs daily/weekly prepayment audit of claims within the guidelines provided and assists in the development and enhancement of the prepayment audit programs for oversight and monitoring of claims related activities and coordination of weekly check run processes
• Perform audit reporting including the Meditrac nightly report, Better Doctors report and other reports accuracy and process improvement identification
• Address provider complaints and provides instruction and oversight to providers when necessary
• Provides guidance to internal and external Claims resources in determining proper courses of action in resolution of Provider claims issues
• Provide guidance to BPO Claims in determining proper courses of action in resolution of Provider claims issues
• Provide guidance to BPO in auditing claims history for recoveries and adjustments for like claims
• Analyzes information to assure resolutions are in compliance with all regulatory and contractual requirements
• Assures timely and accurate resolution of claims issues jointly with internal and external Claims and/or configuration staff
• Answer many claims submission questions and have a good understanding of professional and facility claims processing
• Communicates with providers on resolution and closure of issues, as needed
• Initiates direct communication with providers when additional information is required. Communicates with providers on resolution and closure of issues, as needed
• Initiates direct communication with providers when additional information is required and provides timely updates from BPO Claims and/or Configuration on progress or delays
• Reach out telephonically to physicians and their staffs to follow up on information needed by Gold Coast Health Plan
• Serves as a Claims subject matter expert in analyzing claims issues escalated from internal and external resources.
• Partners with internal and external Claims resources in determining proper courses of action in resolution of Provider claims issues.
• Assures timely and accurate resolution of claims issues jointly with external Claims and/or configuration staff.
• Analyzes provider claims projects.
• Initiates direct communication with providers when additional information is required. Communicates with providers on resolution and closure of issues, as needed.
• Participates in GCHP internal and external meetings established to coordinate and track provider payment issues, as needed.
POSITION QUALIFICATIONS
Competency Statements
• Analytical Skills - Ability to use thinking and reasoning to solve a problem.
• Business Acumen - Ability to grasp and understand business concepts and issues.
• Communication, Oral - Ability to communicate effectively with others using the spoken word.
• Communication, Written - Ability to communicate in writing clearly and concisely.
• Research Skills - Ability to design and conduct a systematic, objective, and critical investigation.
• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
MINIMUM QUALIFICATIONS
Education:
• High School Graduate or General Education Degree (GED): Required
• BA Or Equivalent Experience Preferred
Experience:
• 5 - 7+ years of experience in a claims processing department
• 5 – 7+ plus years of experience in provider relations or related experience
• Medi-Cal/Medicaid managed care experience strongly desired
• Advanced claims and billing knowledge in order to research and resolve claims and authorization issues and/or elevate to other Plan management
• Advanced knowledge of the provider network database
• Advanced knowledge of the provider portal
• Any combination of experience and training that would provide the required knowledge, skills, and abilities would be qualifying
SKILLS & ABILITIES
Computer Skills: Computer proficiency included in the MS Office programs. Advanced Excel Skills
Certifications & Licenses: A current and valid California Driver's License and Insurance.
Other Requirements: Knowledge of:
• Medi-Cal eligibility and benefits.
• Medical billing/coding (CPT, HCPCS, ICD-9/ICD-10); COB/TPL regulations and guidelines. All claim types and standard claims adjudication practices.
• Provider reimbursement methodologies.
• Medi-Cal regulations; working knowledge of Medicare (CMS), and commercial (DMHC). Also requires knowledge of health plan division of financial responsibility (DOFR), and industry “best practices.”
