Tri-City Medical Center has served San Diego County’s coastal communities of Carlsbad, Oceanside and Vista, as well as the surrounding region for more than 60 years and is one of the largest employers in North San Diego County. Tri-City is administered by the Tri-City Healthcare District, a California Hospital District. As a full-service acute care public hospital with over 500 physicians practicing in over 60 specialties, Tri-City is vital to the well-being of our community and serves as a healthcare safety net for many of our citizens. The hospital has received a Gold Seal of Approval® from the Joint Commission showcasing a commitment to safe and effective patient care for the residents of the community.
Tri-City Medical Center prides itself on being the home to leading orthopedic, spine and cardiovascular health services while also specializing in world-class robotic surgery, cancer and emergency care. Tri-City’s Emergency Department is there for your loved ones in their time of need and is highly regarded for our heart attack and stroke treatment programs. When minutes matter Tri-City is your source for quality compassionate care close to home. Tri-City partners with over 90 local non-profit and community organizations as part of our COASTAL Commitment initiative. Together we are helping tackle some of our communities’ pressing health and social needs.
Position Summary:
Under the limited supervision of the Manager, the Senior Claims Processing Analyst is responsible for highly-accurate touch-type data entry and processing of claims for managed care risk contracts along with auditing of transactions that affect the Hospital’s risk contracts to ensure maximum benefit and limited liability. Provides assistance to the department’s personnel with regard to claims adjudication, auditing, benefits and other operational issues, as necessary. Interacts with enrollees, medical groups, providers, hospital staff and administration.
Major Position Responsibilities:
The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization.
- Maintains a safe, clean working environment, including unit based safety and infection control requirements.
- Date stamp, sort and log claims for processing
- Accurately input and process claims into system using touch-type entry in compliance with department guidelines and provider contractual reimbursement methods.
- Review pending claims, audit for errors, post final claims in compliance with department guidelines.
- Maintain/track claims backlog. Report claims backlog information on a weekly basis to the Managed Care Team (the Team).
- Review claims for accuracy and ensure that claims are clean; contact providers as needed to clarify or verify billed services; educate providers on error/omissions in submitted claims.
- Audit and reconcile TCMC valuations using Cerner, MED-MC CPU, Medical Group and/or other system reports to ensure contract compliance and accuracy of reporting information.
- Review all provider appeals related to provider dispute resolution requests.
- Audit detail error/edit reports generated by the system to identify trends and accuracy of claims payment. Document and communicate findings to the Team. System errors should be communicated immediately to ensure the system is processing correctly at any given time.
- Work closely with medical groups, TCMC Business Office and Utilization Management Personnel to verify member eligibility at the time of service along with copay/ coinsurance/ deductible as applicable.
- Process claims payments in compliance with contractual agreements; discuss/verify contractual or rate questions with the Team.
- Interact with internal and external customers (Medical Groups, Providers, and Hospital Personnel) in an appropriate and professional manner. Attend meetings as requested by the Team.
- Communicate all pertinent provider and/ or claim information including findings, problems, concerns or ideas along with possible solutions to the Team in a timely and effective manner.
- Cross train in all appropriate department functions to provide backup as needed.
- Meet specific claims processing productivity targets or requirements (monthly/weekly/daily/) and turn-around times, customer response time; identify operational barriers and present potential solutions to the Team.
- Respond to telephone inquiries from members, providers, vendors and internal staff; provide written replies as needed in compliance with departmental and health plan requirements/ preferences.
- Perform other duties as assigned.
Qualifications:
- Two (2) – Four (4) years’ claims processing/billing, required.
- Highly accurate alpha/numeric data entry using touch-typing, required.
- Understanding of full risk managed care contracts, claims payment practices and benefits, preferred.
- Understanding of capitation methodology/managed care experience, preferred.
- Strong analytical skills, required.
- Ability to work independently, implement processes and oversee the claims processing and auditing component of the operation, required.
- Ability to work under conditions of constant change, deadlines and scrutiny, required.
- Advanced level Excel spreadsheet and Word, required.
- Experience with MED-MC CPU, Cerner System, preferred.
- Knowledge of various Medicare Reimbursement methodologies including DRG’s, APC’s, Medicare Physicians Fee Schedule, Medicare DME Fee Schedule and related Medicare claims processing guidelines, preferred.
- Knowledge of HCPCS, CPT, RBRVS, RVS, CRVS, DRG, ICD-10, ASC and Revenue coding, preferred.
Education:
- High school diploma or equivalent, required.
- College degree, preferred.
Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work.
*Salary/Hourly wage range for this position is posted. Actual pay will be determined based on verified experience as well as internal equity.
TCHD is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with a disability.
