Project Specialist (Claims)

Claims Processing Manager

Responsible for the processing and releasing of professional claims according to established policies and procedures. Identifies procedural and system inefficiencies and work with appropriate entities to resolve issues. Also performs research, analyses, reporting and special projects as needed. Also presents learning material in an organized and logical manner to department personnel on claims processing, including use of the EZCAP system, provider contract interpretation, DOFR, and claim handling procedures. Serves as key point of contact between claims and Data Management and Contracting Unit to resolve any claim payment issues. Added responsibilities include maintaining routine auditing functions and providing feedback on departmental activities, to assure compliance with all health plan and regulatory agencies, including CMS, DMHC, and DCHS. Also responsible for routine audits, complex audits conducted by health plans/CMS/DMHC/DCHS/HPN on focused claims to identify exceptions to established claims adjudication requirements for claims processing, payment and procedural accuracy. Added responsibility with assisting eligibility identifications (e.g. COB, ESRD) and Letters of Agreements as required.

Essential duties and responsibilities include the following:

• Assisting Sr. Claims Manager for any professional claims projects and working with Decision Support/IT/Data Management to resolve issues timely.
• Utilizes standardized processes, tools, methodologies and presentation templates, including: project timetables, progress/milestone reports, financial reports, resource, and issues tracking.
• Accountable for all aspects of project management including: scope planning, scope definition, analysis, activity sequencing, activity duration estimation, schedule development, resource planning, budgeting, project plan development and maintenance, risk management, reporting, implementation, measures development, and project wrap-up.
• Communicates effectively with all claims production staff, as well as with external vendors, consultants and other organizations; Maintains regular contact with Manager and other project sponsors to coordinate project activities as appropriate.
• Provides coaching and support to team members needing assistance in completing assigned tasks. Encourages participation of all team members.
• Identifies potential project risks and implements appropriate courses of action to address project slippage and develop strategies to mitigate future risk. Escalates critical issues for appropriate/timely resolution as needed.
• Monitors time commitments and resources for project teams. Deploys project resources.
• Works closely with Sr. Claims Manager to plan, facilitate, and/or lead team meetings.
• Supports vendor-related activities such as tracking contract stipulations, invoices, and processing data requests.
• Provides technical support, training assistance, and expertise to other project managers and staff through all phases of the project (e.g., Initiation, Analysis, Design, Implementation, and Evaluation).
• Performs all other duties as directed by management.

The pay range for this position at commencement of employment is expected to be between $25 - $27 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.

Education and / or Experience:

• 5+ years' experience Claims processing, preferably EZ-CAP or like systems in the healthcare system.
• 5+ year's healthcare industry experience.
• Strong ability to collaborate with management and other project managers to define business process issues, analyze operational efficiencies, implement creative solutions, and measure delivery results
• Should exhibit a disciplined, process and data-driven approach and methodology
• Knowledge of claims payment policies preferred
• Requires strong organizational, communication and written skills
• Must be able to function with minimal supervision and be able to prioritize all work tasks
• Demonstrated ability to conduct and interpret qualitative and quantitative analysis and problem-solving skills
• Ability to work well with individuals in all levels of the organization; Must be an effective team player
• Demonstrated ability to exercise initiative, independent judgment and be a self-starter
• Strong PC-based business software skills including MS Office suite (Access, Excel, PowerPoint, Word)
• Excellent verbal and written presentation and communication skills