Claims Technician II

Tracking Code 489-798 Job Description SUMMARY DESCRIPTION:Under supervision, this position: 1. Verifies, processes, and/or adjudicates claims, including applying detailed consideration, standards in pending and releasing claims from pend edits and for proper application of program policy related to claim entry and analysis;2. Assists with training new hires and cross-training other Claims Technicians; and3. Performs other duties as assigned. DUTIES AND RESPONSIBILITIES: 1. Verifies, processes, and/or adjudicates claims, including applying detailed consideration, standards in pending and releasing claims from pend edits and for proper application of program policy related to claim entry and analysis, with duties including but not limited to: Processing Level I and Level II claim types; Learning to process high-level claim types normally assigned to the Claims Technician III position; Applying correct procedural codes, modifiers, manual pricing, coordination of benefits and billing limits with appropriate payment status and override notation, as instructed and per established procedures; Appling payment rules per provider/health plan contracted relationships; Researching claims history for duplicates and consideration of benefits/frequency limits; Processing re-billed/tracer claims; and Performing claims and authorization research (e.g. Referral Authorization Forms, Treatment Authorization Requests) verbally and/or via e-mail. 2. Assists with training new hires and cross-training other Claims Technicians. 3. Performs other duties as assigned. EDUCATION AND EXPERIENCE: High School Diploma or equivalent; and A minimum of one (1) year of experience with claims processing in an automated claim environment; or an equivalent combination of education and experience which would provide the required knowledge, skills and abilities may be qualifying. JOB SPECIFIC KNOWLEDGE, SKILLS AND ABILITIES: Working knowledge of medical terminology and related procedure and diagnostic coding (CPT/ ICD, HCPCS), as well as knowledge of how to access available resource tools; Working knowledge of and ability to operate general office equipment, including personal computer, telephone, photocopier, fax, etc.; Thorough knowledge of and the ability to read and understand medical insurance Explanation Of Benefits; Ability to understand current software programs and screens that are required in the daily processing of claims; and Ability to keep abreast of current claims processing practices and procedures. ALLIANCE STANDARD KNOWLEDGE, SKILLS AND ABILITIES: Ability to communicate effectively both orally and in writing; Ability to establish and maintain effective and cooperative working relationships with the Alliance staff and Alliance providers contacted in the course of the work; Ability to assume responsibility and exercise good judgment in making decisions within the scope of authority of the position; Ability to think and work effectively under pressure and accurately complete tasks within established times; Ability to prioritize tasks and meet deadlines; Ability to maintain confidentiality; and Valid California Driver License, transportation and automobile liability insurance in limits acceptable to The Alliance. DESIRABLE QUALIFICATIONS: Knowledge of the Medi-Cal program; Knowledge of Microsoft Word and Excel; and Skill to accurately and efficiently perform 10-key by touch. WORK ENVIRONMENT AND PHYSICAL DEMANDS: Ability to sit in front of and operate a video display terminal and perform 10-key by touch for extended periods of time; and Ability to stand, bend, reach over head, lift, carry or move objects of varying size weighing up to 20 pounds. ALL ALLIANCE EMPLOYEES ARE EXPECTED TO: Comply with all Alliance safety requirements; and Adhere to all Alliance policies and procedures. The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The Alliance reserves the right to revise this job description at any time. Applicants must be currently authorized to work in the United States on a full-time basis. The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. Job Location Scotts Valley, California, United States Position Type Full-Time/Regular Salary Type Hourly Salary 18.53 - 28.21 USD