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Claims Research Specialist

Job ID 85411 Date posted 01/16/2018
  • Facility: Sharp HealthPlan
  • City: San Diego
  • Department: Finance
  • Category: Business Operations Jobs
  • Job Status: Full-Time
  • Shift: Day Job
  • FTE: 1.0
  • Shift Start: 8 AM
  • Shift End Time: 5 PM
This position is located in Kearny Mesa, San Diego County. 
8-hour shift: 8:00 am – 5:00 pm, Weekends as needed.
Required Skills and Qualifications
  • High school diploma or equivalent required
  • Minimum of two (2) years’ experience in a health plan or other health care setting specifically including claims processing
  • Customer service call center, or provider contracting and relations and medical billing
  • Thorough understanding of managed care principles, models, and reimbursement methodologies
  • Familiarity with DMHC and DHS regulations
  • Familiarity with CPT, ICD-9-CM diagnoses and procedures codes as well as any other billing guidelines
  • Must have clear and effective written and oral communication skills, with a solid understanding of English language, including grammar, vocabulary and punctuation
  • Able to follow strict timelines and manage multiple tasks concurrently
  • Able to work independently and as a member of a cohesive, results-oriented team
  • Ability to execute tasks with minimal instruction
  • High level of integrity; ability to maintain confidentiality
  • Able to exercise mature and sound judgment in the commitment of the Plan's mission and operating goals
  • Exceptional diplomacy skills to effectively resolve issues under sometimes tense and stressful circumstances
  • Excellent organizational and interpersonal skills.
  • Computer literate, to include experience with electronic mail, word processing, spreadsheets, and database programs
 Preferred Skills and Qualifications
  • Bachelor’s degree in business or related field or equivalent knowledge/experience in related field
  • Experience with the IDX Managed Care application
  • Specialist or Procedure Coding System Specialist
  • Certified in medical terminology and/or medical billing/coding
  • Certified Professional Coder



The Claims Research Specialist is responsible for researching and resolving complex inquiries and issues related to billing, provider claims adjudication, and payment disputes. Makes timely correction to errors for increased provider and customer satisfaction. Provides education and detailed first level education to providers about their contract, as well as identifying and notifying provider when an error has occurred. Interacts with various internal and external departments (including Claims Department (SDHA) Customer Service, Appeals, Provider Contracting, Health Services and Enrollment) to provide assistance and information. Tracks and trends issues, and makes recommendations for improved contract terms, contract set-up, or claims adjudication policies. Assists in preparation of reinsurance filings.
The Claims Research Department is a small team responsible for a variety of functions such as, researching and resolving complex inquiries and issues related to billing, provider claims adjudication, payment disputes, and MOOP (Member Out of Pocket). The Claims Research Department ensures that errors are resolved in a timely manner for increased provider/customer satisfaction.
Sharp Health Plan is the largest locally based commercial health plan in San Diego. We are a not-for-profit health plan that has been serving San Diego and southern Riverside Counties since 1992. As a subsidiary of Sharp HealthCare, we are backed by the largest provider of comprehensive health care services in San Diego.
Sharp Health Plan offers a variety of coverage options that combine affordability and choice, while delivering high quality health care and personal service. We provide health insurance for companies of all sizes throughout the region. Members have access to valuable plan enhancements, such as interactive wellness resources, dental discounts and our exclusive global emergency services program. 
Essential Physical Requirements may include
  • Spend approximately 4-6 hours per day sitting at desk
  • Entering data on computer terminal and talking on telephone
  • Spend approximately 1-2 hours per day walking between Plan departments
  • Hear and speak clearly by telephone
  • Meet frequent deadlines and tight schedules
  • Lift 5 – 20 pounds, primarily paper reports and filing
  • Sitting
  • Keyboarding
  • Mousing
  • Carry up to 10 pounds
Additional physical requirements of position may be discussed during interview.
Sharp HealthCare is proud to be an Equal Opportunity/Affirmative Action Employer.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, gender identity, transgender status, sexual orientation, protected veteran status or any other protected class.
Keywords: Claims, Certified Professional Coder, Coder, Medical Terminology, Sharp Health Plan

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