Essential Duties and Responsibilities include the following:
Generate additional income, savings and/or reduce the expenses of Regal Medical Group through recoupment and/or recovery of various programs and products, to include but not limited to:
Capitation Deduction:
- Audit all capitation deductions submitted by all the health plans on a monthly basis.
- Dispute unwarranted capitation deductions for each health plan.
- Send overpayments to the provider of service when capitation resulted in duplicate payments.
- Collaborate with Quality Control, Audit, and Claims department for any health plan issues and provide resolution.
- Collaborate with HPN if credits were received as a result of disputes presented to the health plans.
- Ensure Inload of Cap Deducts in EZCAP and entries of recoveries are made.
- Act as liaison to the health plan if there are any capitation deduction issues brought by HPN/RMG.
- Refer to division head health plan issues or other department concerns that are not within the parameters of the internal procedures we have established on capitation deduction.
Lakeside Overpayments:
- Recoup from Lakeside overpayments if the HMO coordinator cannot tackle the heavy work exigencies.
- Review co-pay reports Institutional and Professional when time permits.
- Review LMG Capitation report when threshold of inventory on LMG side persists.
Division of Responsibility Grid:
- Initiate new DOFR Grid for new Medical Group that we acquire
- Update existing internal DOFR for the use of HPN, RMG, LMG, ADOC, GCMG
- Configure DOFR in EZ-CAP for RMG, LMG, GCMG, & ADOC
- Ensure accuracy of DOFR.
- Present to Revenue Recovery Associate any discrepancies found for dissemination to all department heads.
- Attend to emails sent by various departments as they relate to inquiries and potential errors in loading DOFR grid.
Other tasks as Assigned by the division head:
- Review Benefit Matrices and provide input to the division head for preparation of policy and procedures and/or for the use of internal guidelines templates.
- Provide historical data of assigned tasks and contractual guidelines to pursue various revenue recovery projects.
- Implement new projects as assigned by the division head.
Collaborate with the division head claim issues due to Benefit loading errors. If the system was loaded incorrectly and claims were paid as a result of this error, recover from the appropriate payor/s.
Request for system change to apply the correct payor’s responsibility.
- Review contracts to check if Benefit schedules are loaded accurately.
- Present feedback to RRA.
- Participate in the creation and preparation of new departmental policies and procedures.
- Liaison to Madison Healthcare Insurance Services when they need additional information with regard to Stop Loss.
Special Projects as assigned by the division head:
- Audit
- Analysis
- Health plan disputes
- All other duties as directed by management
The pay range for this position at commencement of employment is expected to be $25.00 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.
Qualifications
Education and/or Experience:
- Two (2) years college or equivalent experience is required
- Minimum of 5-year Claims/Benefits/DOFR/Contracts experience in a medical group, Hospital and/or health plan setting is required.
- Ability to deal responsibly with matters of a confidential nature.
- Ability to prioritize work in order to meet daily deadlines.
- Must have excellent communication skills, both verbal and written.
- Ability to read, write and understand the English language.
- Pleasant telephone manner in recovering overpayments from providers.
- Knowledge of HMO, DHS, DMHC, and CMS regulatory guidelines.
- 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 be able to review and interpret health plan benefits and provider contracts.
- Able to interface with customers both internal and external of RMG.
- Ability to communicate effectively orally and written typing 35 words per minute.
- Ability to communicate effectively orally and written answering and resolving 60 to 65 calls per day.
- Strong organizational skills with emphasis on prioritizing and attention to details.
