Claims Adjustment and Dispute Specialist

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. 

At this time, the Health Plan does not sponsor visa. Candidates must have legal and valid work authorization, Green Card, or U.S. citizenship .

This is a remote position.  Must reside in California.  

What You Will Be Doing:

Under general supervision, responsible for researching, resolving and completing disputes and adjustment requests, and other items.

• Reviews submitted provider disputes, researches payment history and submits MND request to UM for review; applies payment or requests refund based on established guidelines; sends out required correspondence. 
• Reviews call logs and resolves or reassigns to appropriate department. 
• Identifies claims error patterns and trends; documents and escalates. 
• Reviews, researches and reprocesses assigned claims.
• Reviews corrected claims and adjustment requests for accuracy, and processes. 

What You Bring: 

Knowledge Skills and Abilities: 

Required:

• Basic knowledge of regulations governing Medi-Cal as they relate to claims processing.
• Basic knowledge of procedure coding and medical terminology, and their application in claims.
• In-depth knowledge of general medical policy benefits and exclusions.
• In-depth knowledge of industry standard payment practices.
• In-depth knowledge of HPSJ systems as they relate to claims processing.
• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
• Strong oral and written communication skills, with ability to express self clearly and professionally, with appropriate grammar and spelling, and document according to standards.
• Ability to work independently and as part of a team.
• Demonstrates a commitment to HPSJ’s strategy, vision, mission and values.
• Basic problem solving and analytical skills, including the ability to perform routine analysis and solve problems using identified data and information.
• Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
• Basic arithmetic skills.
• Basic skills in Windows, Excel, Word and Outlook.
• Ability to handle confidential information with appropriate discretion.
• Ability to speak and be understood in English.

Preferred

• Basic knowledge of claims adjustment processes.

What You Have:

Education and Experience:

Required

• High school diploma or general education degree; and
• At least one year at an analyst I level or equivalent.
• QNEX experience.  

Preferred

• Associate’s Degree.
• Claims adjustment experience.

Licensure, Certification, Registration

Required

• None

Preferred

• Certified in medical coding or auditing

What You Will Get:

 HPSJ Perks:

• Robust and affordable medical coverage including HMO and PPO plan options
• Employee Wellness Program promoting physical, mental, and financial well-being
• Dental and vision plan with multiple provider choices 
• Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, plus a voluntary defined contribution plan
• Two flexible spending accounts (FSAs)for healthcare and dependent care expenses
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Assistance Program (EAP) 
• Health Advocacy to help you navigate medical care and benefits 
• Voluntary supplemental benefits including medical, legal, identity theft protection
• Online discount mall
• Tuition reimbursement 
• Remote work contingent on business needs and company guidelines
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do

Physical Demands

Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements. Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds.

Emotional/Psychological Demands

Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations. 

Work Environment

Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs. For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards.

Important Notice: The duties, qualifications, and physical and emotional requirements listed in this job description are not exhaustive. Health Plan of San Joaquin reserves the right to revise this job description at any time.