Providence is calling a Quality Assurance Specialist ( Full Time / Day Shift ) to our Facey HMO Claims Processing location in Mission Hills, CA.
In this position you will:
- Manage and must be well versed regarding the Provider Dispute Resolution tracking mechanism (AB1455).
- Responsible for claims member appeals and claims phone inquiry adjustments. Must be able to process different types of claims.
- Serves as a liaison between contracted health plans, patients, hospitals and the Information Technology Department.
- Must be familiar with applicable State and Federal claim payment and denial timeliness legislation.
- Must be familiar with Timeliness Compliance pursuant to State and Federal rules and regulations.
- Responsible for ensuring customer (provider-vendor) satisfaction while maintaining the integrity of Facey's vision and business objectives.
- Demonstrates a high level of integrity and innovative thinking and actively contributes to the success of the Team.
- Supports, encourages and models attitudes, actions and behaviors that will make Facey the best in the industry in customer measured quality and responsiveness requirements.
Required qualifications for this position include:
- Bachelor's degree or equivalent combination of education and/or experience.
- 10 or more years HMO claims processing experience in a managed care environment, preferably PMG/IPA setting within the last seven years or any combination of education and/or experience which produces an equivalency.
- Comprehensive knowledge on claims reimbursement methodologies, data elements and coding.
- Strong knowledge of HMO membership, plan benefits, plan designs and health plans protocols on enrollment in a managed care environment.
- Extensive knowledge of medical terminology, HMO claims processing guidelines including EDI Claims, and government claim processing regulations.
- Knowledge of AB 1455 Provider Dispute Resolution Mechanism and its application according ICE guidelines.
- Proficient with producing reports via Access and Excel, data analysis and ability make mathematical calculations.
- Must possess excellent oral and written communication skills and computer skills. Proficient use of Microsoft Word, Excel, Access, Outlook, and PowerPoint.
- Must display a high level of flexibility and attention to detail.
- Must possess excellent customer service and communication skills, be organized and a self-starter.
About the organization you will serve:
Facey Medical Group is a multi-specialty medical group with over 160 physicians providing care to the growing population in the North & East regions of Los Angeles & Ventura Counties. Twelve medical clinics, including two urgent care centers and dedicated women's centers, are located across the San Fernando, Santa Clarita and Simi Valleys. The group began as a single medical practice over 90 years ago.
Facey is part of Providence Health & Services, an integrated, not-for-profit 5-state network of hospitals, care centers, medical clinics, affiliated services and educational facilities spanning from California to Alaska.
We offer a full comprehensive range of benefits - see our website for details
As people of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.
Providence Health & Services is the third largest not-for-profit health system in the United States. Providence employs more than 82,000 caregivers (employees) across a five-state area; AK, WA, MT, OR, and CA. Our facilities include 34 hospitals, 600 physician clinics, senior services, supportive housing and other health and educational services. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Quality & Patient Safety
Location: California-Mission Hills
Req ID: 149215