Claims Appeals/ Pre-Logger

Claims Adjudication Specialist

Responsible for entering primary claims data onto the claims adjudication system. In addition, this position checks member eligibility and/or data enter information onto the claims system.

Essential duties and responsibilities include the following:

• Adheres to data integrity policies for all system configurations.
• Ability to adjudicate CMS1500, UB92/UB04 and other types of claim forms.
• Ability to perform mathematical calculations and analytical duties for specialty services.
• Proficient in multiple areas of data management look-up (fee sets, benefits, eligibility, contracts, provider set up, vendor, claims processing).
• Responsible for the accurate and timely completion of tasks assigned and adhering to hourly/daily production standard in accordance with established policies and procedures.
• Process pre-log of claims with an accuracy rate not to fall below 97%.
• Research all problem claims and make decisions in a timely manner.
• Identify issues that may influence compliance standards and notify supervisor or lead immediately.
• Communicates with management and makes recommendations to improve processes.
• Maintains a customer satisfaction focused, service mentality to strengthen and build relationships with Heritage Provider Network and other Regal Medical Group.
• Interpret and implement provider and HMO contracts.
• Attends administrative meetings as requested.
• All other duties as directed by management.

The pay range for this position at commencement of employment is expected to be between $21 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.

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:

• Excellent written and verbal communication skills.
• Knowledge of claims processing.
• Knowledge of HIPAA regulations for security, privacy and transactions.
• Knowledge of EDI transaction formats.
• Typing/data entry skills and accuracy.
• Proficient in the use of personal computers, including MS Office applications.
• Internet access and browsing.
• Medical group or IPA operations information systems management experience preferred.
• Understanding of the health care industry, benefits and eligibility processes preferred.
• Appropriate industry experience and/or certification preferred.