Department: 500620 Reimbursement Svcs
Facility: Hometown Health
Reno, NV
Schedule: Full Time - Eligible for Benefits
Shift: Day
Hours: 0800 to 1700
Job Details:
  • Position Purpose:

    Under the direction of the Manager of Business Analysts, this position oversees all daily claims processing operations and functions.  This position is responsible to ensure timely and accurate processing of claims for HMO, PPO, TPA and Dental products for commercial and senior members, fully funded and self-funded. Claims shall be adjudicated according to health plan procedures, Department procedures, State and Federal Regulations and Laws, member benefits and provider contractual agreements. Under the direction of the Manage of Business Analysts, this position will develop and implement the Coordination of Benefits and Subrogation portions of claims adjudication for the health plan.  This position will develop and implement training programs for coordination of benefits and subrogation as it pertains to claims processing.  This position is also responsible to ensure training for other Hometown Health Departments, provider offices and employer groups. 

     

    Nature and Scope:

    This position is responsible for all claims processing and COB/Subrogation functions, including documentation, system input and procedures to ensure timeliness and accuracy and to comply with State and Federal regulations and laws, provider contractual issues and health plan procedural issues. This position shall determine, through research, including state and federal laws and regulations, Department of Insurance and attorneys, health plan participation in coordination of benefits and subrogation programs.  Upon determining the participation, this position shall develop policies, procedures and processes to ensure appropriate claims processing to correspond to the health plan programs. This position shall assist in developing and implementing collection/recovery efforts for subrogation.   This position shall assist to ensure appropriate financial procedures are developed to ensure coordination of benefits and subrogation monies are deposited and credited to the appropriate fund/member.  This position shall be responsible to approve all legal matters in regards to COB/Subrogation functions.  This position is responsible for human resources issues, including hiring, disciplinary action and termination. This position is responsible to recommend and/or make necessary changes in staffing to ensure accurate and timely claims processing. This position is responsible to delegate work, establish appropriate timeframes and implement necessary procedures and protocols to ensure accurate and timely claims processing.  This position is responsible to work with other Departments to ensure appropriate communication and procedures are established within the Health Plan.  This position is responsible, when appropriate, to represent the health plan to vendors, providers, employer groups and members.  This position has the authority to develop and implement claims processing procedures.  This position is responsible to ensure the current processing and support procedures are updated.   This position shall be responsible to complete projects as assigned by the Claims Manager or other health plan management.  This position shall participate in quality improvement and change management procedures and processes.

     

    This position does not provide patient care.  

    The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

    Minimum Qualifications:  Requirements - Required and/or Preferred

    Education:

    Must have working-level knowledge of the English language, including reading, writing and speaking English.

    Experience:

    Five (5) years experience, including on-line claims processing.  Experience should include HMO, PPO, TPA and Dental products for commercial, senior and Medicaid.  Thorough knowledge and application of CPT, ICD9, HCPCS, ASA, ADA, DRG coding.  Medical terminology.  Ability to interpret health plan benefits knowledge and coverage.  Ability to interpret provider contracts.  Knowledge of State Regulations and HCFA guidelines.  Knowledge of coordination of benefits and third party liability.  Two (2) years supervisory experience.

    License(s):

    N/A

    Certification(s):

    N/A

    Computer / Typing:

    Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.



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