What are the responsibilities and job description for the Managed Care Claims Resolution Specialist position at University of California?
UCSD Layoff from Career Appointment : Apply by 02 / 10 / 25 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor.
Special Selection Applicants : Apply by 02 / 20 / 25. Eligible Special Selection clients should contact their Disability Counselor for assistance.
Candidates hired into this position may have the ability to work remotely, after training.
DESCRIPTION
Under direction of the Provider Network Management / Contracts Manager, incumbent serves as the primary contact for incoming provider, health plan, and internal and external department calls, including documentation and follow-up via Epic CRM, as required for claims delegation compliance. Responsible for requesting, tracking and trending overpayment recoveries and adjustments for voided checks and refunds. Interprets and utilizes contract and benefit information to accurately process managed care claims for all lines of business, including COB adjudication. Responsible for Provider Dispute Resolution acknowledgements, ensuring responses are within CMS & DMHC guidelines. Investigates and presents complex cases to management for resolution. Interfaces with other departments to resolve eligibility, referral and Network Management related claim issues. Responsible for claim adjustments on previously processed claims related to a member out of pocket share cost. Prepares cost share worksheets to the health plans as requested. Other duties as assigned.
MINIMUM QUALIFICATIONS
Three (3) years relevant experience in a healthcare environment. One (1) year claims data entry and / or processing experience.
Knowledge of current HMO claim adjudication protocols and guidelines and health plan delegation requirements.
Working knowledge of CPT, ICD, ASA, and HCPCS coding as it pertains to claims administration.
Proficiency with MS Office : Excel, Word, Outlook, etc.
Excellent communication skills, both verbal and written.
PREFERRED QUALIFICATIONS
Epic Tapestry system experience.
Managed Care experience.
Epic Claims experience.
SPECIAL CONDITIONS
Must be able to work various hours and locations based on business needs.
Employment is subject to a criminal background check and pre-employment physical.
Pay Transparency Act
Annual Full Pay Range : $40,700 - $85,295 (will be prorated if the appointment percentage is less than 100%)
Hourly Equivalent : $19.49 - $40.85
Factors in determining the appropriate compensation for a role include experience, skills, knowledge, abilities, education, licensure and certifications, and other business and organizational needs. The Hiring Pay Scale referenced in the job posting is the budgeted salary or hourly range that the University reasonably expects to pay for this position. The Annual Full Pay Range may be broader than what the University anticipates to pay for this position, based on internal equity, budget, and collective bargaining agreements (when applicable).
Salary : $40,700 - $85,295
