Job DescriptionClaims AnalystHealth and Human Services Division, IHCHow we serve our community: Polk HealthCare Plan: *~* If you are a current BoCC employee, you must apply on PolkOne via the ME tab in PolkOne! *~*Are you Inspired by Service?Do you enjoy analytics and independent problem solving while still working in a collaborative environment?Can you maintain a high level on integrity, and handle tough conversations with providers?Starting Pay: Pay Grade 17 $26.14 Hourly, Non-ExemptPay Grade Progression Range: Pay Grade 17, $26.14 to 39.21 Hourly, Non-ExemptPhysical Location: Golfview Ave, Bartow, FLStandard Operating Hours: Weekdays 8:00AM to 5:00PMEmployee BenefitsDirect Deposit, Bi-Weekly Pay ChecksMedical, Dental, VisionLife InsuranceFlorida Retirement System Participation10 Paid HolidaysPaid Time OffTuition ReimbursementEducation IncentivesDeferred Compensation PlanWellness IncentivesEmployee Assistance Program (EAP)Free Employee GymFree Employee Health ClinicWe are a Certified Age-Friendly EmployerDrug-Free WorkplaceMust have the physical, developmental, and mental ability to perform job tasks, work efforts, responsibilities and duties of the job illustrated below: MAJOR FUNCTION
- Responsible for monitoring performance guaranties of claims processed by Third Party Administrator (TPA) and Pharmacy Benefits Manager (PBM) for the Polk HealthCare Plan (PHP).
- Establish a rapport with health plan members and providers to ensure that all claims issues are addressed in a timely manner by the TPA.
- Provide final resolution for PHP second level claims appeals. Responsible for the recoupments of PHP claims.
- Responsible for processing claims submitted due to Health Care Responsibility Act (HCRA).
- Prepare and submit HCRA quarterly financial report to the Agency of Health Care Administration (AHCA).
ILLUSTRATIVE DUTIES
- Track and monitor performance compliance of TPA and PBM agreements.
- Review, request, and track recoupments for PHP.
- Review and respond to appeals for the PHP.
- Respond to request from attorneys related to the PHP.
- Oversee the administration, reporting compliance and claims processing for the Health Care Responsibility Act (HCRA) per Florida Statutes 154.301-154.331 to provide payment for Polk indigent out-of-county emergency care.
- Handle inquiries via telephone/correspondence from providers, members, and other staff members regarding status of account. Ability to make mathematical computations and tabulations accurately and with reasonable speed. Investigate provider and customer complaints and non-conformance issues.
- Collect and compile statistical quality data.
- Analyze data to identify areas for improvement by TPA and PBM and contractors.
- Reviews and recommends updates in established policies/procedures.
- Identifies needs and makes recommendations of action as indicated to assure adequate and cost-effective access to health care. Reviews regulations and communicates their impact, either verbally or in writing, through designated channels of authority.
- Prepare reports to communicate outcomes of quality activities for TPA and PBM appropriate corrective actions.
- Assure TPA and PBM ongoing compliance with quality and industry regulations.
MINIMUM QUALIFICATIONS
- Graduate of an accredited four (4) year college or university with a bachelor's degree in business administration, healthcare administration, or a related field; and five (5) years of experience in a health care setting, including billing of services and the appropriate use of ICD9, HCPCS, CPT, Revenue and Place of Service codes.
- Must possess a valid driver's license and be able to secure a valid Florida driver's license at the time of employment.
- A comparable amount of related training and experience may be substituted for the minimum qualifications.
SPECIAL REQUIREMENTSMust undergo a Level 2 (FDLE) screening submitted electronically before commencing work. Those obtaining this certification must maintain certification as a condition of employment.Must be willing to work beyond normal working hours when necessary. When circumstances warrant, such as a time of impending or declared disaster (i.e. hurricanes, tornados, flooding, etc.), the person filling this position will be expected to be available to participate in the Polk County Emergency Management Plan. The Emergency Management duties may require the employee to be away from their home and family for several consecutive days.This position may be required to report for work when a declaration of emergency has been declared in Polk County.About Polk County, FLSeventeen municipalities, ranging from a tiny village to a metropolitan city, are located in Polk County, along with twenty-four unincorporated, populated areas. Incorporated Polk County: City of Auburndale, City of Bartow, City of Davenport, Town of Dundee, City of Eagle Lake, City of Fort Meade, City of Frostproof, City of Haines City, Village of Highland Park, Town of Hillcrest Heights, City of Lake Alfred, Town of Lake Hamilton, City of Lakeland, City of Lake Wales, City of Mulberry, City of Polk City, City of Winter HavenUnincorporated Polk County: Babson Park, Ghost Town of Brewster, Combee Settlement, Citrus Ridge, Crooked Lake Park, Crystal Lake, Cypress Gardens, Fussels Corner, Gibsonia, Highland City, Homeland, Inwood, Jan Phyl Village, Kathleen, Lakeland Highlands, Loughman, Medulla, Nalcrest, Pittsburg, Poinciana, Wahneta, Waverly, Willow Oak, Winston