Job Description

**This role is available remotely in Washington State Only.

Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

• Strive to a pply an equity lens to all our work.
• Reduce health disparities.
• Create an equitable work environment.

About the Role

Responsible for conducting focused claim reviews and identifying and facilitating claim adjustments based on results found through Community Health Plan of Washington claim reviews or as identified by internal Community Health Plan of Washington departments. Responsible for sustaining processes and executing process improvement and quality monitoring. Responsible for contacting providers regarding negative balance collections.

Additionally, the role involves investigating and resolving escalated claims issues raised by internal Community Health Plan of Washington (CHPW) departments and committees. The incumbent monitors departmental compliance with state and CMS requirements, including managing the collection and submission of operational performance metrics and required data reporting. Finally, the position serves as a subject matter expert for Claims Recovery, contributing to companywide or specialized projects to improve processes and ensure accurate claims management.

To be successful in this role, you:

• Have minimum two (2) years claims operations experience required, with proven broad knowledge and execution of quality improvement methods and tools or related experience. Experience in managed care preferred.
• Have Medicaid Coordination of Benefits (COB) and Medicare Secondary Payor (MSP) experience preferred.
• Have prior experience encouraging timely repayment from providers preferred.
• Possess an understanding of the healthcare industry, specifically in the Operations area.
• Have a GED or High School diploma or an equivalent combination of education and highly relevant experience in healthcare.

Essential functions and Roles and Responsibilities

• Identify and conduct focused and random claims audits.
• Provide research for providers in a negative balance over 45 days.
• Create demand letters and support collections effort.
• Contacts providers to request refunds.
• Regularly submit subrogation referrals.
• Facilitate claim adjustments and system remediation as required.
• Receive and research escalated claims issues identified by internal Community Health Plan of Washington departments and committees.
• Regularly monitor departmental contractual compliance with state and CMS requirements including managing the collection and submission of required operational performance metrics and data reporting requirements.
• Participate in companywide or specific projects as a subject matter expert for Claims Recovery.

Knowledge, Skills, and Abilities

• Analytical skills.
• Project management skills and team facilitation skills.
• Communication skills, both verbal and written.
• Technical and process documentation skills.
• Ability to work repetitive tasks.
• Ability to work well with different people at all levels within the organization.
• Ability to analyze, organize and prioritize work, while meeting multiple deadlines.

Note: If you think you do not qualify, please reconsider. Studies have shown that women and people of color are less likely to apply to jobs unless they feel they meet every qualification. However, everyone brings different strengths to the table for a job, and people can be successful in a role in a variety of ways. If you are excited about this job but your experience doesn’t perfectly check every box in the job description, we encourage you to apply anyway.

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check.

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
• Vaccination requirement (CHPW offers a process for medical or religious exemptions)
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits

The position is FLSA Non-Exempt and is eligible for overtime and has a 5% annual incentive target based on company, department, and individual performance goals. The base pay actually offered will take into account internal equity and also may vary depending on the candidate’s job-related knowledge, skills, and experience among other factors.

CHPW offers the following benefits for Full and Part-time employees and their dependents:

• Medical, Prescription, Dental, and Vision
• Telehealth app
• Flexible Spending Accounts, Health Savings Accounts
• Basic Life AD&D, Short and Long-Term Disability
• Voluntary Life, Critical Care, and Long-Term Care Insurance
• 401(k) Retirement and generous employer match
• Employee Assistance Program and Mental Fitness app
• Financial Coaching, Identity Theft Protection
• Time off including PTO accrual starting at 17 days per year.
• 40 hours Community Service volunteer time
• 10 standard holidays, 2 floating holidays
• Compassion time off, jury duty

Sensory/Physical/Mental Requirements:

Sensory*

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*

• Extended periods of sitting, computer use, talking and possibly standing.
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.
• Frequent torso/back static position; occasional stooping, bending, and twisting.
• Some kneeling, pushing, pulling, lifting, and carrying (not over 25 pounds), twisting, and reaching.

Mental

• Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability.

Work Environment:

• Office environment. Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.