County of Alameda

DESCRIPTION

Under general supervision, to plan, coordinate and manage the activities of the Behavioral Health Care Claims Processing Center; to ensure that operational procedures are in compliance with policies and procedures of the Behavioral Health Plan and generally accepted claims processing practices and standards; and to perform other related duties as assigned.

Distinguishing Features

This single position is located in the Behavioral Health Care Services, Claims Processing Center and reports to the Supervising Financial Services Specialist. The Health Care Claims Manager plans, coordinates and manages the activities of the Claims Processing Center and exercises full supervisory responsibility for this unit. This class is distinguished from the lower class of Health Care Claims Examiner II in that the latter processes claims for payment and verifies eligibility for a variety of insurances plans/programs, which does not include supervisory responsibilities. It is further distinguished from the next higher class of Supervising Financial Services Specialist, in that the latter has overall administrative responsibilities for the Provider Relations Unit.

EXAMPLES OF DUTIES

NOTE: The following are illustrative examples of duties performed by this classification. However, employees may perform other related duties at an equivalent level. Not all duties are necessarily performed by each individual in this classification.

1. Plans, coordinates and manages the activities of the Behavioral Health Care Services, Claims Processing Center.
2. Establishes and evaluates the goals and objectives for the Claims Processing Center.
3. Develops, implements, interprets policies and procedures as they relate to the Claims Processing Center.
4. Recruits, interviews, hires, trains, evaluates and disciplines the Health Care Claims Examiners I/II and support staff.
5. Researches and evaluates the status of Provider contracts in order to determine payment.
6. Reviews recommendations for claims appeal decisions for submission to the Financial Services Officer.
7. Monitors provider performance for claims submission activities and reports incidences and patterns of non-compliance with Federal, State, local and Plan policies and procedures to Provider Relations for documentation and possible corrective action.
8. Approves requests for credit of paid claims.
9. Acts as liaison with the managed care Behavioral Health Plan ACCESS program, Authorization unit, other County departments/agencies and contracted providers in regard to all issues relating to provider payments.
10. Resolves issues on the status of claims.
11. Coordinates and/or conducts on-going training and development for staff.
12. Monitors internal auditing functions.
13. Ensures that operational procedures are in compliance with policies and procedures of the Behavioral Health Plan and generally accepted claims processing practices and standards
14. Provides management reports and productivity performance information to the Supervising Financial Services Specialist.
15. In collaboration with the accounts payable section of the Finance Unit, ensures appropriate bank account balance levels for payment disbursement to providers.

MINIMUM QUALIFICATIONS

Either I

The equivalent of two years full-time experience in the Health Care Claims Examiner II or higher classification in the Alameda County classified service. (Non-classified includes District Attorney’s Office, Hospital Authority, and the Consolidated Courts.)

Or II

The equivalent of three years full-time experience in reviewing, evaluating, editing and processing claims for payments, and determining eligibility for a variety of insurance plans/programs in a health care environment. One year of the above experience must include lead and/or supervisory experience.

NOTE: The Civil Service Commission may modify the Minimum Qualifications in the announcement of the examination.

KNOWLEDGE AND SKILLS

NOTE: The level and scope of the following knowledge and abilities are related to duties listed under the "Examples of Duties" section of this specification.

Knowledge of:

• Management principles and practices, including work planning, employee supervision and resource allocation
• Applicable health care laws and regulations
• Parameters of a provider’s contract obligations.
• Current policies and requirements for an array of administered insurance plans (e.g. Medi-Cal, Healthy Families, and Children’s Indigent Plan) and other regulations as they relate to insurance benefit plan/program eligibility.
• Basic policies and operations of health care insurance plans.
• Federal, State and local health care rules and regulations as they relate to claims processing.
• Computer applications related to the work.
• Office administrative practices and procedures, including records management and the operation of standard office equipment.
• Basic mathematical computation.

Ability to:

• Plan, supervise, review and evaluate the work of staff.
• Interpret, explain and apply complex regulations, policies and procedures.
• Prepare clear, accurate and effective reports, correspondence, policies, procedures and other written materials.
• Represent the department and the County in meetings with others and make effective presentations to diverse groups.
• Organize, prioritize, and coordinate multiple activities to meet critical deadlines
• Direct the maintenance of accurate records and files.
• Exercise sound independent judgment within established policies and guidelines.
• Exercise interpersonal sensitivity to establish and maintain effective working relationships with staff, clients, other agencies, and the public.
• Analyze, evaluate and draw logical conclusions.
• Maintain confidentiality.
• Communicate effectively orally and in writing.
• Work independently and adapt to change.

CLASS SPEC HISTORY

DRH:po 12/19/07
Newspec: 1463.doc
CSC Date: 2/13/2008

BENEFITS

Alameda County offers a comprehensive and competitive benefits package that affords wide-ranging health care options to meet the different needs of a diverse workforce and their families. We also sponsor many different employee discount, fitness and health screening programs focused on overall well being.  These benefits include but are not limited to*:

For your Health & Well-Being

• Medical – HMO & PPO Plans
• Dental – HMO & PPO Plans
• Vision or Vision Reimbursement
• Share the Savings
• Basic Life Insurance 
• Supplemental Life Insurance (with optional dependent coverage for eligible employees)
• Accidental Death and Dismemberment Insurance 
• County Allowance Credit
• Flexible Spending Accounts - Health FSA, Dependent Care and Adoption Assistance
• Short-Term Disability Insurance
• Long-Term Disability Insurance
• Voluntary Benefits - Accident Insurance, Critical Illness, Hospital Indemnity and Legal Services
• Employee Assistance Program

For your Financial Future

• Retirement Plan - (Defined Benefit Pension Plan)
• Deferred Compensation Plan (457 Plan or Roth Plan)

For your Work/Life Balance

• 12 paid holidays
• Floating Holidays
• Vacation and sick leave accrual
• Vacation purchase program
• Management Paid Leave**
• Catastrophic Sick Leave
• Pet Insurance
• Commuter Benefits Program
• Guaranteed Ride Home
• Employee Wellness Program (e.g. At Work Fitness, Incentive Based Programs, Gym Membership Discounts)
• Employee Discount Program (e.g. theme parks, cell phone, etc.)
• Child Care Resources
• 1^st United Services Credit Union 

*Eligibility is determined by Alameda County and offerings may vary by collective bargaining agreement.  This provides a brief summary of the benefits offered and can be subject to change.

** Non-exempt management employees are entitled to up to three days of management paid leave. Exempt management employees are entitled to up to seven days of management paid leave.