Outside Medical Services Claims Specialist

SUMMARY: The OMS Claims Specialist is responsible for all aspects reviewing and processing charges and claims submitted by vendors rendering services to Alameda Health System patients, who have been authorized by Case Management and/or the Social Workers for services that are not provided within the AHS system.DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

The OMS Clams Specialist is responsible for accurately processing provider / facility AHS facility claims in a timely manner while adhering to the contractual requirements of the CMS policies and procedures. The claims specialist will have the following responsibilities:

Processing, examining and adjudicating claims.

Utilize the appropriate claims software including Cap Connect and OMS database to insure authorizations are valid.

Identifying issues or trending and provide suggestions for findings and claims activity performed.

Review the vendor information, to validate contracts and applications are up-to-date.

Manage and maintain worklist inventory, complete reports, and resolve high priority and aged inventory.

Respond timely to emails and telephone messages as appropriate. Communicate issues to management, including payer, system or escalated account issues.

Maintains information or operational records.

Validates there’s no other insurance on patients profiles. Prepares correspondence to communicate denials and pertinent information to the vendors / providers.

Reviews billing documents to assure program compliance for Medicare, Medi-Cal, and other programs.

Other duties as assigned.

MINIMUM QUALIFICATIONS:Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.Required Education: High school diploma or equivalent education.Minimum Experience: One year of experience in a Revenue Cycle area within the Alameda Health System; OR the equivalent of two years’ experience, performing medical billing or claims examiner functions in a healthcare insurance related environment.