The County of Santa Clara – Valley Health Plan


Under general supervision, to examine and process medical claims submitted to Valley Health Plan from all lines of business for medical services provided to Valley Health Plan members and other at risk groups assigned to the Health Plan or to the Management Services Organization. COVID 19 Risk Tier: Lower Risk

Typical Tasks

Examines, processes, and pays medical claims submitted by medical service providers to Valley Health Plan;
Reviews claim documents, including electronic claims (EDI), for required data elements including eligibility, benefits, authorization, and appropriate medical coding;rejects incomplete or duplicate documents;
Ensures correct payment of claims per provider contract and follows all claims processing rules as outlined in CA title 28 for Medi-Cal, Medicare and other insurance providers;
Ensures that all claims payments and denials are accurate and that the appropriate denial letter is issued to a member, provider, institution or organization;
Adheres to California State Department of Managed Care regulations and established timelines for examining and processing medical claims;
Confirms provider reimbursement rates as necessary;
Accesses the First Health Care Network, National Health Care Network and Medi-Cal/Medicare and other programs to verify pricing of claims submitted by providers who do not have a contract with VHP and recalculate pricing as needed;
Responds to incoming calls from providers regarding status of their claims, including Researching the Diamond claims processing system for check numbers, cancelled checks, W-9’s, remittance advices and Explanation of Benefits (EOB’s);
Enters complete claims information into the claims database accurately and in a timely manner;
Researches and resolves difficult claims issues, disputed claims, claims needing additional information, pending claims reports, reject reports, aging reports, error reports, and other reports to ensure claims are processed within established time frames and quotas;
Obtains input from Provider Relations, Member Services and Utilization Management departments as necessary for making a claims decision;
Requests overpayments and make additional payments for underpaid claims as necessary within authorized dollar amounts;
Researches and documents sources of medical insurance;
Maintains daily log of all activities, including number of claims processed and special projects completed;
Informs supervisor of irregularities in claims submitted, including potential fraud and abuse issues;
Keeps current with claims processing and procedure documents;
Assists in orienting new employees;
Performs various clerical duties such as mail pickup, stamping, sorting and batching incoming claims, researching tracers, and returning claims to providers;
Participates in education and training as required by the Plan, SCVHHS or the County;
May be assigned as a Disaster Service Worker as required;
Performs other related duties as assigned.

Employment Standards

Sufficient education, training and experience to demonstrate possession of the knowledge and abilities listed below. Experience Note: The required knowledge and abilities are typically acquired through graduation from high school or equivalent and one (1) year experience examining and processing medical insurance claims in the health care industry. Knowledge of:

Practices, standards, methods and procedures of effective claims adjudication in the health care industry;
Modern office administrative practices and procedures including computer office applications;
Medi-Cal, Medicare and other insurance program regulations and managed care claims processing;
Commercial insurance regulations in a managed care environment;
Medical terminology, Concurrent Procedure Terminology (CPT), ICD-9 Coding, and other available resource reference tools;
Automated health care claims processing systems;
Principles and practices of customer service and telephone courtesy;
State and Federal regulations for the examining and processing of insurance claims.

Ability to:

Work independently with minimal supervision;
Demonstrate exceptional interpersonal skills;
Prioritize work and respond to changing and/or conflicting demands in a dynamic work environment;
Operate a computer and use word processing applications;
Provide clear and concise information to health care providers and in response to other Department inquiries both verbally and in writing;
Research and analyze reimbursement claims and/or reports to ensure that claims are processed accurately and in a timely manner;
Establish and maintain cooperative working relationships with all levels of medical, professional, administrative, support personnel, and the public;
Perform basic math calculations and operate a ten-key adding machine;
Provide excellent customer service;
Adapt and function efficiently in a production oriented environment.

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