Member Services Auditor

Regal Medical Group•Los Angeles, CA

11h

About The Position

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.

Requirements

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.

Responsibilities

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.