Nov 08, 2018

Claims Research Specialist I

  • Sutter Health
  • Sacramento, CA
Full time Health Care

Job Description

**Description** The Claims Research Specialist researches, analyzes and adjudicates claims resubmitted because of denial problems, incorrect payment, contract issues, appeals and grievances to determine if the claim is payable. Anticipate and recognize problems associated with processing of complex claims, which may include a variety of elements requiring independent judgment. Consistently evaluate applicable policies and procedures and recommend changes as appropriate. Perform special projects as requested. **Qualifications** **Education** + High school graduate, or equivalent, required **Experience/Knowledge** + Five years claims processing experience required + Working knowledge of office procedures and understanding of a managed care organization is required + Thorough knowledge of RBRVS, CPT, HCPCS, and ICD-9 coding and medical terminology required + Working knowledge of COB, TPL, and Medicare rules and regulations + Experience using the DRG and APC pricer + Thorough understanding of standard payment rules required + Knowledge of state and federal regulations as it pertains to claim interest calculation and compliance + Knowledge of client specific rules and regulations, and pricing mechanisms + Work experience in a healthcare or other manage care claim processing environment setting highly desired **Skills** + Able to analyze and solve complex claims issues + Ability to correctly interpret health plan benefits and contractual provisions + Ability to compute rates and verify balances + Working knowledge of personal computers, including basic knowledge of Word, Excel and Microsoft Outlook + Able to work independently and make decisions using good judgment and initiative + Able to efficiently prioritize assignments + Excellent communication skills, both written and verbal + Able to use a calculator and basic office equipment, including copy and fax machines **Primary Location:** California, Greater Sacramento Area, Sacramento **Organization:** Sutter Physician Services **Employee Status:** Regular **Employee Referral Bonus:** No **Benefits:** Yes **Position Status:** Non-Exempt **Union:** No **Job Shift:** Day **Shift Hours:** 8 Hour Shift **Days of the Week Scheduled:** Monday-Friday **Weekend Requirements:** None **Schedule:** Full Time **Hrs Per 2wk Pay Period:** 80 All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity or expression, ancestry, national origin (including possession of a driver's license issued to individuals who did not present proof of authorized presence in the U.S.), age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy or perceived pregnancy, childbirth, breastfeeding or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screening. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.


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