Qureos Mentor

Kern Health Systems

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).
 
KHS reasonably expects to pay starting compensation for the position of Claims Operations Senior Specialist, in the range of $35.89 - 45.76 hourly.
 
**Hybrid Position**
 
About us
 
Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.
 
About the role
 
This highly specialized position is responsible for analyzing statistics of all areas of Claims daily; and assisting in priority area as needed. This position is responsible for knowing and performing all functions within the department: Claims Processing, Auditing, Disputes/Rework, Calls, Training, Inventory Control, Systems Testing, Overpayments, and Encounter Processing – and offering suggestions for improvements to Management. This position is also responsible for keeping abreast of Medi-Cal, Commercial and Medicare rules for Dual membership or other LOB (Dental, Vision, LTC, Transplants, Mental Health, Pharmacy, etc.) and training when necessary.
 This position is responsible for identifying area most in need of attention and applying their knowledge and skill to help that specific area to be within operating standards/goals. This position will be required to perform all functions within Claims Operations. This position will use experience to identify areas to improve in workflow, system enhancements, and Auto Adjudication. This position will also be the primary SME for all other Lines of Business from Medicare to Commercial or other new benefits for Medi-Cal.
 
Essential Duties and Responsibilities
 
<ul>
<li>Analyze and identify (on a daily basis) area in Claims Department needing most assistance to hit optimal benchmarks.</li>
<li>Perform Claims Processing at all levels, Auditing, Dispute Processing, Calls, Overpayments, Encounter Processing, Training, Inventory Control and System Testing at optimum levels as needed with flexibility day to day.</li>
<li>Analyze via reports and experience in daily handling of all related department duties and recommend changes to work processes as needed.</li>
<li>Analyze via reports and experience in daily handling of all related department duties and recommend system enhancements/Auto Adjudication as needed.</li>
<li>Write and run reports in Business Objects as needed.</li>
<li>Acts as a resource and provides support to Customer Service and Provider Relations regarding Claims Payments.</li>
<li>Track and trend Provider disputes, denials and calls to effect improvement in compliance with billing rules and/or opportunities for Provider Training.</li>
<li>Key contact and oversight of Supplemental Payment programs via the Claims Department (Prop 56, GEMT, etc.).</li>
<li>Liaison with High Dollar Claim Review Vendor – monitor, verify, and validate data as well as communicate needs to vendor.</li>
<li>Performs other job-related duties as required.</li>
<li>Adheres to all company policies and procedures relative to employment and job responsibilities.</li>
<li>Telecommuting jobs will require some on site meetings/ trainings as identified by management.</li>
</ul>
Employment Standards: 
Bachelor’s degree in business from an accredited university or equivalent required AND ten (10) years of direct experience in combination of a minimum of eight (8) functions: Claims Processing, Auditing, Provider Dispute Processing/Rework, Claim Call Representative, Training, Inventory Control, System Testing, Overpayment Recovery, and/or Encounter Processing. Experience in Medicare, Medi-Cal and Commercial lines of business required.
 <ul>
<li>OR-</li>
</ul>
Fourteen (14) years of direct experience in combination of a minimum of eight (8) functions: Claims Processing, Auditing, Provider Dispute Processing/Rework, Claim Call Representative, Training, Inventory Control, System Testing, Overpayment Recovery, and/or Encounter Processing. Experience in Medicare, Medi-Cal and Commercial lines of business required
 
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.

Claims Operations Senior Specialist

Join Kern Health Systems and explore 1   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Kern Health Systems

About Company

Claims Operations Senior Specialist