Claims Analyst
5 days ago
This position is directly responsible for researching and maintaining coordination of benefits of all contracted and non-contracted health plan entities as reported by any health plan, provider, Medicare, TPL, Workers Comp or internal departments. They are to ensure that all EZ-Cap system eligibility data is current and accurate. Researches and maintains systems and changes to existing eligibility in a timely manner.
Education and/or Experience:
- A bachelor’s degree from a four-year college or appropriate industry experience and/or Certification.
- 3 years office experience in Managed Health Care.
- Proficient in SQL, Access, and EZ-Cap.
- Must have knowledge of HMO, PPO, EPO, POS, Government Funded, Medicare and Medicaid plans
- Must have knowledge of the Department of Managed Healthcare COB guidelines
- Experience with Windows, Microsoft Office programs, and Outlook.
- Experience in Customer Service, multi-tasking, and organization.
- Good verbal and written communication skills.
- Computer literate with keyboard skills for data entry.
Essential Duties and Responsibilities include the following:
- When a COB requests are received from internal departments and corporate employee will determine if the health plan and CMS reflect correct COB information.
- Staff will contact the health plan and verify if the policy is an active employer group policy (large or small) or a retiree policy and obtain a retiree date.
- Staff will contact the member to confirm their employer group status, active or retired. (Only when the health plan cannot confirm a retiree date, number of employees or any other pertinent information necessary to establish COB according to Medicare guidelines)
- Staff will notify the employer group to advise them the health plan shows member actively employed, when per the member, they are retired.
- Review Medicare guidelines to determine if they have obtained all the necessary information from the health plan, employer group, or member to establish correct COB.
- Contact the CMS COB unit to report that there is or there is no COB if CMS shows Medicare Secondary Payer information.
- Document in EZ-Cap in the notes field of all activity, calls, CMS MSP status, etc. and respond to appropriate departments of any changes in coordination of benefits.
- Update COB field in EZ-Cap to reflect correct MSP status according to Medicare guidelines even when CMS & health plan do not yet reflect correct MSP.
- Follow up with CMS and the health plan in 5 to 10 business days to verify information has been update by both CMS and the health plan. (Continue to follow up with CMS, health plan and member if necessary)
- Communicates verbally and supplies a summary of COB status at weekly Membership meetings. Is responsible of educating staff and keeping up with changes in Medicare Guidelines.
- Maintains End Stage Renal Disease Database. Communicates ESRD updates to all appropriate departments.
- Performs research and analysis of membership
- Enters new member eligibility records into EZ Cap in accordance with established guidelines.
- Uses activity analysis reports from the health plans to make changes to existing enrollees; i.e. benefit option changes, terminations, and address changes.
- Manually audits existing eligibility in EZ Cap against current eligibility.
- Investigates retroactive cancellations for services rendered by the member after the policy termination date for eligibility guarantee.
- Researches problem eligibility on authorizations and/or claims forms by calling the health plans or utilizing any other source to resolve the problem.
- Assists personnel from other departments with eligibility issues.
- Monitors queue, web site and email for inquiries. Responds timely to membership inquiries.
- Any other duties as assigned by Lead or Department Head.
- All other duties as directed by management.
The pay range for this position at commencement of employment is expected to be between $27 - $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.
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