Job description

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and Cal MediConnect (Medicare-Medicaid Plan) health insurance plans.

About the role:

The Provider Dispute Resolution Intake Specialist is responsible for the daily intake and determination of appropriate classification, priority and routing of new and existing provider claim disputes and for ensuring that all Provider Dispute Resolutions (PDRs) received are created and tracked in accordance with state and federal regulatory requirements and SCFHP policies and procedures as set forth for each line of business.

Day to Day:

• Successfully accomplish the timely intake, categorization, tracking and reporting of PDRs.
• Perform complete, accurate and consistent data entry of PDR information into the databases in accordance with policies and procedures and instruction from department management; evaluate data input and output for accuracy to ensure data integrity.
• Assess the priority level of each PDR and ensure PDRs include the necessary elements prior to routing to the appropriate staff.
• Ensure PDR cases are accurate and include the necessary elements for processing prior to forwarding to the appropriate PDR Analyst.
• Acknowledge PDRs timely to meet SCFHP policies and procedures and state and federal regulatory requirements.
• Create and mail acknowledgment and determination letters to providers in a manner that meets required timeframes.
• Participate in retrospective audit and review of PDR cases and complete and correct gaps or errors in data.
• Contact providers to seek additional information or clarification regarding PDRs and assist the PDR Analysts and department management in requesting medical records or other pertinent information related to PDRs.
• Provide administrative support to the Manager of Provider Dispute Resolution with activities related to the completion of reports required for regulatory or business purposes.
• Maintain an effective PDR file storage and maintenance system consisting of hard copy storage and secure destruction and online retrieval as required for audit and business purposes.
• Accurately enter data from medical claims into claims system, as needed.
• Provide back-up support for the Claims Clerk, as needed.

About You:

• High School Diploma or GED.
• Minimum one year of experience in a claims or grievance and appeals department in managed care or health care environment in a data capture role.
• Detail-oriented with the ability to conduct research and identify details of PDR cases.
• Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the Claims operations as dictated by business needs.
• Ability to review PDRs and system data to determine appropriate and timely handling of PDRs by achieving regulatory standards.
• Ability to consistently meet the Quality and Productivity Key Performance Indicators by participating in and achieving the Claims/PDR Quality Standards.
• Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, and Excel.

Please review the full job description and apply on our Career’s page: https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=1084

Job Type: Full-time

Pay: $23.47 - $34.03 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Tuition reimbursement
• Vision insurance

Schedule:

• Monday to Friday

Application Question(s):

• Do you have a minimum of one year of experience in a claims or grievance and appeals department in managed care or health care environment in a data capture role?

Education:

• High school or equivalent (Preferred)

Work Location: One location

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