Overview:

This position is located in Redding, California as an onsite role

To research and resolve complex claims issues which cross interdepartmental lines and communicate the outcome to providers and affected PHC managers. Develops and maintains provider training materials for all lines of business. Conducts provider training across PHC departmental lines in a group or individual provider settings.

Responsibilities:

• Answer customer service lines as necessary and responds to provider inquiries either by phone, email, or in person regarding claims-related questions.
• Reviews, researches, and works with various departments to resolve complex provider inquiries, appeals, and grievances.
• Acts as a resource and provides support to customer service staff, as well as Provider Relations staff for complex Provider questions regarding claims and payments.
• Coordinates with Claims, Member Services, and Health Services departments, for the development, maintenance, and training of ongoing educational materials and tips for inclusion on the PHC website. Incorporates educational materials into the PR Manual and updates on a quarterly basis.
• Processes CIFs and adjustments as needed.
• Writes and runs reports in Business Objects to obtain needed claim data.
• Tracks and analyzes provider trends with denials and CIFs to provide support to providers with an opportunity to improve. Distributes provider scorecards.
• Tracks complaints, appeals, and grievances by the program. Reports activities on a quarterly basis to IQI, PHC Compliance Coordinator, and Claims Director.
• Presents findings and recommendations for ongoing, long-term resolutions to issues. Identifies items to address the “provider hassle factor.”
• Acts as a liaison and meets with designated staff from Claims, Health Services, Member Services, and QI departments to identify ongoing provider issues.
• Coordinates system issues with Claims Configuration staff, IT staff, and PR Lead Project Specialist/Auditor. Leads or participates in special projects as needed.
• Other duties as assigned

Partnership HealthPlan of California provides a range of employment options, including remote, hybrid, and onsite positions are not eligible for remote or Hybrid schedules. Each role has specific requirements that must be met. Prospective candidates must be residents of California and possess a valid driver's license and auto insurance. Additionally, they should be available to work onsite for a minimum of 90 days initially.

Qualifications: