Program Coordinator II / 60014090

Are you the One? We are looking for a Program Coordinator II who works in the Office of Claims Resolution and is an integral member of the Claims Resolution Team. This candidate will process assigned medical claims pended for manual review in assigned workflow roles. They will accurately interpret benefit and policy provisions applicable to line of business. They will review claim information to determine coverage based on contract, provider status, and claims processing guidelines.

• Review claim submission and documentation for completeness and validity to determine payment/rejection according to member's plan benefits and department claims processing policies and procedures. Recognizes, document, and refer any potential fraud, waste, and abuse situations. Follows the agency privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Demonstrate a knowledge of relevant policies and procedures that impact claims processing decision points. Identify potential conflicts and share information with team and supervisor to eliminate delays and need for additional processing steps. In addition, adhere to management policies and procedures, business process improvement, and performance requirements within guidelines.
• Collaborate with other agency employees and external stakeholders, as necessary. Aligned with strategic objectives, identify and focus on priorities that will deliver results for our bureau and our members. Acts with proactive intent to improve claims related outcomes.
• Meets professional development goals as assigned by management. Participates in cross training opportunities. Coordinates the creation of individual professional development plan with manager. Monitors progress toward continuing professional development.
• Performs other duties as assigned adhering to all program, agency, State and other related policies, procedures, privacy and timeline standards.

• Health, Dental, Vision, Long Term Disability, and Life Insurance for Employee, Spouse, and Children.
• 15 days annual (vacation) leave per year.
• 15 days sick leave per year.
• 13 paid holidays.
• State Retirement Plan and Deferred Compensation Programs.

A bachelor's degree and one (1) year of experience in healthcare claims payment operations.

An equivalent combination of experience and education may be considered with prior State Human Resources approval.

Preferred: Healthcare Customer Service experience.

Additional Requirements:

• Sitting or standing for long periods of time.

• Ability to develop thorough understanding of Medicaid claims process and health insurance terminology.
• Knowledge of laws, regulations, policies and procedures relevant to the claims processing and related services.
• Ability to communicate effectively.
• Research skills and ability to evaluate claims in order to process accurately.
• Proficiency in Microsoft Office and internet/web navigation.
• Ability to prioritize work and perform under time constraints with minimal direct supervision.
• Ability to utilize and provide claims mentorship to other team members as needed.
• Team player willing to collaborate and help others accomplish team objectives.

Please complete the State application to include all current and previous work history and education. A resume will not be accepted nor reviewed to determine if an applicant has met the qualifications for the position. Supplemental questions are considered part of your official application for qualification purposes. All applicants must apply online. All correspondence from the Office of Human Resources will be through electronic mail.

The South Carolina Department of Health and Human Services is committed to providing equal employment opportunities to all applicants and does not discriminate on the basis of race, color, religion, sex (including pregnancy, childbirth or related medical conditions, including, but not limited, to lactation), national origin, age (40 or older), disability or genetic information.

Salary : $46,655 - $86,321