MEDICAL CENTER DESCRIPTION:

Located in the greater South Bay-Harbor area of Los Angeles County, the medical center is a free-standing, non-profit 400+ bed facility with over 2600 employees and a medical staff of more than 900 physicians.  The facility is a top 100 U.S. hospital (awarded four times by Solucient) and has top scores in Best Overall Quality, Best Emergency Services, Most Preferred Hospital, and Most Preferred for cancer treatment, heart care, outpatient surgery, and senior services.

POSITION PURPOSE:

This position is responsible for managing the Medical Center’s delegated claim processing responsibilities, including appropriate and timely adjudication of outside provider claims for which the medical center is financially responsible, supervision of claims processing staff, maintenance of the claim adjudication system and interaction with the system vendor as needed, compliance reporting and audits, coordination with other department staff, interaction with affiliated medical groups and hospital departments, and other functions as may be required to maintain compliance with state and federal regulations, departmental standards and organizational values. Position serves as Principal Officer for Claims Settlement Practices and Dispute Resolution.

REPORTING RELATIONSHIPS:

This position reports to the Director of Managed Care.

PRIMARY DUTIES AND RESPONSIBILITIES:

1.         Ensures appropriate and timely adjudication of outside facility, professional and ancillary claims according to industry requirements, applicable contract provisions and department policies. Initiates check printing for release of approved claim payments.

2.         Manages database and functionality of the claim adjudication system, including data entry and troubleshooting; identifies system development and improvement opportunities; interacts with system vendor as needed.

3.         Supervises daily work activities of Claims Processors. Provides training and guidance to Claims Processors. Audits Claims Processors’ performance for quality assurance and compliance purposes. Completes required performance evaluations of Claims Processors.

4.         Prepares and submits monthly and quarterly reports to health plans and/or regulatory agencies as required.

5.         Prepares and participates in periodic health plan claim compliance audits.

6.         Ensures maintenance of complete and accurate claim files, including inventory of claims received but not fully adjudicated.

7.         Oversees submission of complete and accurate encounter data to health plans.

8.         Attends industry training as appropriate.

9.         Provides timely and effective communications to providers, medical group staff and hospital staff.

10.       Demonstrates behaviors that are consistent with the medical center values of service, excellence, knowledge, stability and community.

11.       Demonstrates superior communication and customer relations skills.

12.       Ensures that privacy and confidentiality rules are followed in accordance with the Medical Center, State, federal and HIPAA laws and regulations.

13.       Performs other duties as directed by supervisor.

INTERPERSONAL RELATIONSHIPS:

Interacts with Medical Center directors, physicians, staff, medical group staff, and the payor community.

WORK ENVIRONMENT/HAZARDS:

Office environment.  Potential offsite meetings.

POSITION QUALIFICATIONS:

College degree. Minimum two years’ manager-level experience in medical claims processing for an HMO or other risk bearing organization (i.e., medical group or hospital) with direct supervision of claims processing staff and responsibility for maintenance of claim adjudication systems. Demonstrated expertise processing claims for facility, professional and ancillary services, including identification of billing errors, and appropriate application of state and federal law and regulations, contract terms, coordination of benefits, third party liability and reinsurance coverage. Demonstrated knowledge of risk sharing models and ability to interact with medical group staff. Requires excellent communication skills and proficiency in Microsoft Word and Excel.