California Children Services Specialist

Community Health Group; Chula Vista (CA); On-site; USD 33,000 - 50,000; Full time

Job summary

Community Health Group in California is seeking an Administrative Support worker to assist in coordinating care for CCS-eligible children. You will help identify eligible members, develop reports, and submit CCS applications within 5 business days, while coordinating with staff, providers, and CCS to ensure timely processing.

The role emphasizes data review, documentation, and adherence to CMS/Medicaid and CHG policies, with a focus on accuracy and continuous improvement in CCS coordination.

Qualifications

• High School Graduate.
• Medical terminology and/or coding certificate required.
• Experience in a health care setting.
• Familiarity with CCS, Medi-Cal and other government programs preferred.
• Knowledge of Microsoft programs (word processing, spreadsheets, and databases).
• Familiarity with CPT, ICD-9, HCPCS and Medi-Cal coding; CCS Program or similar government programs desirable.

Responsibilities

• Assists in improving the identification of members who are medically eligible for the CCS program by utilizing current CCS guidelines and established policies and procedures.
• Develops reports to identify possible cases or diagnoses and working with department staff to maximize opportunities to identify potential CCS eligible cases.
• Submit applications within 5 business days of case identification to CCS program and ensure no applications are returned or rejected as incomplete.
• Review cases pending CHG determination based on medical documentation submitted by practitioners to CCS; work with staff and providers to obtain completed application or information needed to complete the application.
• Research CCS denials for possible appeals; maximizing interface with local CCS staff to ensure all potential CCS reviews are completed timely and accurately.
• Improve and restructure CHG's system for documenting CCS in coordination with the CCS on-line system and assist with overall coordination of care for CCS-eligible children.
• Maintain CHG MIS system current with CCS determinations based on research of the CCS on-line system.
• Document and communicate coordination of care for CCS-eligible children by reviewing claims submitted to CHG for potential CCS-eligible services; reviewing the status of CHG cases pending CCS determination on an ongoing basis; updating the CHG system once CCS decision is completed; working with staff, case managers, and providers to obtain necessary medical information to facilitate CCS case review.
• Improve identification to 100% of pharmaceutical use linked to CCS-eligible conditions by reviewing drug utilization reports to identify potential CCS-eligible members; reviewing drug profiles of established CCS-eligible members to identify drugs that are linked to the CCS-eligible condition; identifying members/medication combinations that are carved out for payment by CHG; working with Pharmacy Services Coordinator to educate pharmacy network on CCS policies and procedures.
• Maintain complete and current knowledge of the CCS program's policies and procedures to achieve 100% compliance with CCS program requirements and identification of opportunities for improvement by working with key staff to stay current and updated on CCS Program policies, procedures, and guidelines.

Skills

Communication skills

Data gathering and analysis

Verbal and written communication

Cross-functional teamwork

Education

High School Diploma

Medical terminology/coding certificate

Tools

Microsoft Word

Databases

Excel

Job description

EEO-1: Administrative Support WorkersPOSITION SUMMARYAssists with the coordination of care with the local CCS program to identify and refer children with CCS-eligible conditions.COMPLIANCE WITH REGULATIONSWorks closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D and Special Needs Plan (SNP).RESPONSIBILITIESAssists in improving the identification of members who are medically eligible for the CCS program by utilizing current CCS guidelines and established policies and proceduresDevelops reports to identify possible cases or diagnoses and working with department staff to maximize opportunities to identify potential CCS eligible cases.Submit applications within 5 business days of case identification to CCS program and ensure no applications are returned or rejected as incomplete.Review cases pending CHG determination based on medical documentation submitted by practitioners to CCS;Work with staff and providers to obtain completed application or information needed to complete the application.Research CCS denials for possible appeals; maximizing interface with local CCS staff to ensure all potential CCS reviews are completed timely and accurately.Improve and restructure CHG's system for documenting CCS in coordination with the CCS on-line system and assist with overall coordination of care for CCS-eligible children. Maintain CHG MIS system current with CCS determinations based on research of the CCS on-line system.Document and communicate coordination of care for CCS-eligible children by reviewing claims submitted to CHG for potential CCS-eligible services; reviewing the status of CHG cases pending CCS determination on an ongoing basis; updating the CHG system once CCS decision is completed; working with staff, case managers, and providers (primary, specialty, ancillary, and facilities) to obtain necessary medical information to facilitate CCS case review and assist in developing processes to document overall coordination of care for CCS eligible children.Improve identification to 100% of pharmaceutical use linked to CCS-eligible conditions by reviewing drug utilization reports to identify potential CCS-eligible members; reviewing drug profiles of established CCS-eligible members to identify drugs that are linked to the CCS-eligible condition; identifying members/medication combinations that are carved out for payment by CHG; working with Pharmacy Services Coordinator to educate pharmacy network on CCS policies and procedures; working with Member Services staff to re-direct members to CCS pharmacy providers.Maintain complete and current knowledge of the CCS program's policies and procedures to achieve 100% compliance with CCS program requirements and identification of opportunities for improvement by working with key staff to stay current and updated on CCS Program policies, procedures, and guidelines.Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.EDUCATIONHigh School Graduate.Medical terminology and/or coding certificate required.EXPERIENCE/ SKILLSExperience in a health care setting.Familiarity with CCS, Medi-Cal and other government programs preferred.Knowledge of Microsoft programs (word processing, spreadsheets, and databases).Familiarity with CPT, ICD-9, HCPCS and Medi-Cal coding; skillful at using personal computers and software; experience with CCS Program or similar government programs desirable.Ability to communicate effectively verbally and in writing.Skillful at data gathering and analysis; working in cross-functional teams.Ability to organize work effectively and determine priorities.PHYSICAL REQUIREMENTSProlonged periods of sitting at desk and working at a computer terminal; intermittent standing, walking, bending, stooping, lifting 10 lbs. or less.May be necessary to work and attend meetings outside of facility or normal business hours.The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.