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Operations and Provider Support Analyst I
ZipRecruiter, Camarillo, California, United States, 93012
Position Summary
Under the direction of the Senior Operations Manager, the Operations and Provider Support Analyst I 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. Work Schedule: Remote. Flexibility to work beyond normal business hours as needed. 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. 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. Essential Functions
Act as a liaison between Gold Coast Health Plan and the provider community to effectively resolve provider issues, address concerns and resolve problems 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 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 background, role, or job type. Minimum Qualifications
Education: High School Graduate or General Education Degree (GED): Required Experience: 2 -3 plus years of experience in a claims processing department 2 -3 plus years of experience in provider relations or related experience Medi-Cal/Medicaid managed care experience strongly desired Intermediate to advanced claims and billing knowledge in order to research and resolve claims and authorization issues and/or elevate to other Plan management Intermediate to advanced knowledge of the provider network database Intermediate to 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. Proficient Excel Skills 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) Industry “best practices.”
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Under the direction of the Senior Operations Manager, the Operations and Provider Support Analyst I 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. Work Schedule: Remote. Flexibility to work beyond normal business hours as needed. 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. 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. Essential Functions
Act as a liaison between Gold Coast Health Plan and the provider community to effectively resolve provider issues, address concerns and resolve problems 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 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 background, role, or job type. Minimum Qualifications
Education: High School Graduate or General Education Degree (GED): Required Experience: 2 -3 plus years of experience in a claims processing department 2 -3 plus years of experience in provider relations or related experience Medi-Cal/Medicaid managed care experience strongly desired Intermediate to advanced claims and billing knowledge in order to research and resolve claims and authorization issues and/or elevate to other Plan management Intermediate to advanced knowledge of the provider network database Intermediate to 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. Proficient Excel Skills 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) Industry “best practices.”
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