Lead Claims Examiner

Job Description

Position Summary:

To evaluate and determine the appropriate path and to assist in the expedited processing of all claims, special projects and escalated reconsiderations originating from various internal and external sources and to serve as the first level of telephonic and written response for such issues.

Essential Duties And Responsibilities Include The Following

• Maintain the workflow of all departmental projects.
• Provide reports and on-going updates to Claims management.
• Assist in the processing of claims, special projects and medical records from all sources.
• Oversees staff activities to maintain high level of productivity.
• Monitor claims related functions to ensure health plan and regulatory compliance.
• Participate with training determined by unit Supervisor regarding claims adjudication issues discovered in audit or through appeals.
• Perform audits of claims activities such as turnaround time for acknowledgement, forwarding of claims to correct payer, and processing timeframes.
• Provide primary support to the Supervisor of the Institutional unit including special projects.
• Recommend process improvements based on appeal tracking and trending reports.
• Support Claims management in other company functions such as Medical Review management.
• Handle and document resolution to escalated telephone and written claims.
• Implement and coordinate issue resolution processes.
• Liaison for department with outside providers and internal departments.
• Provide supervisory coverage for Claims unit as needed.
• All other duties as directed by management.
  
  

The pay range for this position at commencement of employment is expected to be between $28 - $30 per hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health And Wellness

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services
  
  

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance
  
  

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage
  
  

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

Requirements

Education and / or Experience:

• High School Diploma and 3 years adjudication experience in a managed care setting.
• Knowledge of CPT-4, HCPCS, Hospital Revenue, and ICD-9 coding.
• Knowledge of HMO, DHS, DMHC, and CMS claims processing guidelines.
• Strong knowledge of Microsoft Windows environment such as Word and Excel.
• Self-starter, willing to take on multiple tasks.
• Must meet minimal claims adjudication production standards.
• Strong knowledge of Coordination of Benefits (COB) applications.
• Must be able to interpret health plan benefits.
• Must be able to review, interpret and apply contract rates.
• Ability to communicate effectively orally and written typing 35 words per minute.
• Strong organizational skills with emphasis on prioritizing and attention to details