Member Services Auditor (Blue Shield) - Regal Medical Group : Job Details

Job DescriptionPosition Summary:Provides support in the ongoing maintenance and configuration of Regal Medical Group systems, including but not limited to the data entry of Contracting Database, Providers, Vendors, Fee schedules, Capitation Configuration. Performs system maintenance functions in a manner that is responsive to customer needs and support Regal initiatives.Essential Duties and Responsibilities include the following:

• Adheres to Data integrity policies for all system configurations.
• Responsible for the data entry of claims system support tables and may be required to perform specialized area data entry or general data maintenance for eligibility, providers, fee sets and benefits or any other areas that require ongoing.
• Proficient in multiple areas of data management (fee sets, benefits, eligibility, contracts, provider set up, vendor).
• Responsible for the accurate and timely completion of tasks assigned.
• Performs random audits as required to support policies and procedures for data integrity.
• Communicates with management and makes recommendations to improve processes.
• Ensure all systems within their area of responsibility are reliable, responsive and support to the needs of the Regal Medical Group network.
• Maintains a customer satisfaction focused, service mentality to strengthen and build relationships with Heritage Provider Network and other Regal Medical Group.
• The provider adds report is run daily to identify if provider needs to be added to system.
  • The report must be sorted by Pend flags status and then received date.
  • Pending for Eligibility are priority and must be completed same day.
  • Receive date greater than 5 days from current date are priority must be completed same day.
  • Receive date less than 5 days from current date must be completed with 3 - 4 days.
• Contracted TIN or Provider must be verified if provider is contracted via CDB access database.
  • If provider is not found, must flag provider with PC (Pending Credentialing) flag.
  • If provider is found under a different TIN must via email contact assigned Network Manager to confirm if provider is part of the contracted group/TIN and/or TIN changed.
  • If provider is found all criteria's match, add provider and link Key ID to referral network(s).
• Non Contracted TIN or Provider is validated if Provider or TIN not found as in the CDB database.
• Provider must be loaded as non-contracted by applying our U C standard rates.
• Individual and Group NPI must be validated via NPI Registry.
• Vendor Name must be validated via IRS website.
• Facility with health plan reciprocity contract worked on a daily basis.
  • Reciprocity rates apply when facility and HPN have not contract. The facility will accept Health plan rates as payment.
  • Identify high volume non-contracted providers.
  • P:/Finance/hospital reciprocity rates worksheet if provider is listed.
  • 5 - 7 facilities must be complete on daily day in all databases (LMG, GCMG, and RMG).
• Attends administrative meetings as requested.
• Provides training to other staff members in data management.
• All other duties as directed my management.

The pay range for this position at commencement of employment is expected to be between $23 - $25 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.RequirementsEducation and/or Experience:

• High School Graduate or equivalent required.
• 3 year experience in medical office, related field, including customer service duties
• 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.
• Working knowledge of MS Word.
• Working knowledge of MS Excel.