Careers

Job Description
The Claims Processor is responsible for accurately and consistently adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy. The Claims Processor shall process claims according to all CMS and DMHC guidelines. Investigates and completes open or pended claims. Meets production and quality standards at all times and is familiar with Compliance Standards (HIPAA).

POSITION INTERACTS WITH

• Administration Department
• UM/QM Department
• Contracting/Credentialing Department
• Case Management
• Finance Department
• Human Resource Department
• Physicians
• Health Plans
• Vendors

ESSENTIAL DUTIES & RESPONSIBILITIES
While upholding and supporting the philosophy, objective and policies of Qualcare the essential duties and responsibilities include the following, other duties may be assigned:

• Meets productivity standards for a number of claims completed and for accuracy of entries
• Handles in a professional and confidential manner all correspondence while adhering to HIPAA and Compliance Regulations
• Supports Qualcare core values, policies, and procedures.
• Receives, and adjudicates medical claims for processing; reviews scanned, EDI, or manual documents for pertinent data on claim for complete and accurate information.
• Receives daily workflow via reports or work queue and incoming phone calls
• Researches claims for appropriate support documents
• Analyzes and adjusts data, determines appropriate codes, fees and ensures timely filing and contract rates are applied.
• Responds and documents resolution of inquiries from internal departments.
• Assists Finance with researching provider information to resolve outstanding or stale dated check issues
• Performs Provider Dispute Request (PDR) fulfillment process from the point of claim review through letter processing and records outcome in applicable tracking databases
• Assists maintaining and developing Claims Policies and Procedures
• Must maintain professional etiquette working with external customers and interacting with staff
• Must be proficient in Microsoft Office programs – Excel, Word, PowerPoint, etc
• Must be able to research authorizations, claims, eligibility, and compliance items raised by physician practices or health plan partners.
• Ability to handle provider concerns in an empathetic and caring manner
• Review bills for appropriateness based on individual contracts.
• Re-price medical claims per network provider terms through our EZcap System
• Responsible for answering provider phone inquiries for claims and payment status
• Online data entry of network re-pricing
• Run reports as required
• Deny/misdirect claims to appropriate Payor
• Maintain and follow up on pending claims, as required by guidelines
• Review supporting documentation for accuracy
• Copying, scanning, and filing as required
• Assisting Manager or Director to draft provider documents including formal letters, faxes, certified mail, and drafting of these documents as assigned
• Ensures that payers adhere to compliance laws regarding timely processing of claims.
• Familiar with Claims Reporting guidelines
• Familiar with Eznet and OfficeAlly
• Other duties as assigned by the Manager/Director
• Ability to prioritize and multitask a large work volume with a high level of efficiency and attention to detail

QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions

Knowledge of :

• ICD-10, HCPCS, and CPT coding *is a must for contract interpretation and loading*
• Health plan/vendor contracting
• Division of Financial Responsibility (DOFR) and interpretation for accuracy of claims payments
• Company policies and procedures
• Microsoft office applications and Excel spreadsheets specifically: pivot tables, sorting, and filtering
• EZ-CAP System
• EzNet
• OfficeAlly, EDI, Bowman
• DRG/Per Diem/SNF
• Experience understanding / writing algorithmic type logic

Ability to:

• Problem-solve, negotiate and demonstrate independent decision-making
• Prioritize with excellent organizational skills, responding to multiple demands and timeliness
• Demonstrate professional written and verbal communication skills and presentation skills using the English language
• Demonstrate project management skills, including the ability to plan a project and stay within plan and budget
• Demonstrate ability to respond to common inquiries from patients, customers, vendors, regulatory agencies, health plans or member of the business community and possess excellent customer service skills
• Twist, turn and utilize reaching motion, ability to sit and/or stand for extended periods of time

SKILLS
Has knowledge of industry standards and expectations. Has knowledge of commonly used concepts, practices and procedures within this field. Excellent verbal and written skills. Computer literate with knowledge of EZ-Cap and Microsoft Applications. Relies on experience and judgment to plan and accomplish goals. Performs a variety of tasks. Works independently under the direction of the Claims Manager. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

EDUCATION and/or EXPERIENCE
High school diploma and at least (5-10) year related experience and/or training. Experience is mandatory.

LANGUAGE SKILLS
Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, or government regulations. Ability to write reports and/or business correspondence. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

MATHEMATICAL SKILLS
Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations for reporting and actuarial purposes.

REASONING ABILITY
Ability to solve practical problems and deal with a variety of concrete variable in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Job Type: Full-time

Job Functions:

• Assist with monthly financial closings
• Analyze and reconcile general ledger accounts
• Prepare and post journal entries from source documents and perform account activity analysis
• Prepare and distribute monthly reports to appropriate personnel
• Assist with the annual budget preparation as needed
• Assist with bi-annual audit pack submission and all other audits
• Reconcile bank accounts monthly
• Prepare reports for AP/Payroll
• Perform other special projects and duties as assigned

Education:

• Bachelor's Degree preferred; degree in Accounting highly desired

Experience:

• Previous accounting experience in a healthcare setting highly desired

Knowledge, Skills and abilities:

• Knowledge of financial statements and general ledger accounting
• Understanding of hospital accounting preferred
• Thorough knowledge of automated accounting systems and spreadsheet applications, including Excel and Word
• Effective communication skills, both oral and written
• Problem solving and troubleshooting skills
• Effective time management and organization skills
• Strong interpersonal skills
• Ability to perform effectively, both independently and with a team

Job Type:

• Full-time

Required education:

• Bachelor's

Job Type:

• Full-time

Job Description:
We are looking for a qualified Content/Technical Writer to join our team with experience in healthcare. You will be responsible for helping create, improve and maintain online content to achieve our business goals. Your duties will also include sharing content to raise brand awareness and monitoring web traffic and metrics to identify best practices. As a Content writer, the candidate should perform well under deadlines and be detail-oriented and also be knowledgeable in content optimization and brand consistency.
DUTIES & RESPONSIBILITIES:

• Understand our business as well as the technology and terminology behind all our services.
• Collaborate with appropriate clinical, product and healthcare Subject Matter Experts
• Create content for digital, print, blogs, and more. You should expect that every interaction with our clients will have your mark.
• Help create and define marketing strategies that reach and engage the most customers possible.
• Be the expert. Have confidence and understanding of our services.
• Be meticulous. Refined copy has a profound impact on audiences. Help us polish every last detail prior to publishing.
• Develop content strategy aligned with short-term and long-term marketing targets
• Collaborate with marketing and design teams to plan and develop content, style and layout
• Help create and publish engaging content (Content and experience pages)
• Write blog posts and targeted emails based on company’s campaigns
• Optimize content according to SEO best practices
• Manage content distribution to online channels and social media platforms to increase web traffic
• Develop an editorial calendar and ensure content team is on board
• Ensure compliance with law (e.g. copyright and data protection)
• Stay up-to-date with developments and generate new ideas to draw audience’s attention
• Sufficient understanding of basic marketing metrics to write content that helps achieve specific project objectives
• Ability to contribute recommendations or suggestions that add value to the marketing plan of a project beyond the writing assignment
• Content will be driven through the following areas:
  • Blogs
  • Newsletters
  • Social Channels
  • Websites
  • Video
  • Print Media

REQUIREMENTS :

• Bachelor’s degree in English, Journalism, Marketing, or other related field.
• At least 3 years of proven experience as a content/technical writer, copywriter, or similar role.
• Writing experience in Healthcare
• Familiarity with web publication, social media, and other content outlets.
• Excellent writing and editing skills in English.
• Portfolio of content writing, projects, or published articles.
• Excellent computer and typing skills.
• Strong attention to detail with a keen eye for grammatical errors.

DUTIES & RESPONSIBILITIES:

• Provide on-site (hospital, skilled nursing facility) and/or telephonic inpatient case management and concurrent review for identified hospitalized members.
• Monitor medical necessity, appropriateness and efficiency of care using established inpatient guidelines, contacting Supervisor, Physician, Specialist, Hospitalist, and Medical Director as needed.
• Coordinating and assisting with discharging patients from hospitals and SNFs.
• Coordinating transfer of patient to in network facilities when appropriate.
• Participate in discussion of delays / barriers / progression of care at care coordination rounds or in 1:1 meetings with physicians, specialists and/or hospital staff.
• Be knowledgeable of patient’s available benefits / coverage / payor information.
• Be knowledgeable of community programs and resources available to patients within their benefit plan.
• Prioritize daily workload to ensure efficiency in completing daily work (patient discharge needs are met, guidelines are followed with proactive discussion of delays / barriers to efficient care, data entry is completed).
• Facilitate communication between patient, family, physician, social services, and vendors to maintain continuity of care and appropriate use of resources.
• Serve as a resource to patients, providers, and internal departments. Facilitate and comply with application of benefits processes as needed in close coordination with medical director and care team. Perform utilization management for HealthPartners members admitted to Out of Network Facilities, acute rehabilitation facilities, facilitating the approval/denial of services provided.
• Assist in monitoring of annual financial goals for inpatient case management LOS, readmission’s, and denial rates, cost savings, patient/provider satisfaction and achievement of outcomes.
• Remain current with knowledge and skills of case management and utilization management practices, application of guidelines, policies and procedures related to case management.
• Remain current with knowledge to ensure compliance with government programs such as Medicare / Medicaid requirements and regulations.
• Discuss cases not meeting medical criteria and cases with utilization issues with physician, social worker, other care team members and medical director as needed.
• Assist in monitoring of annual goals for case management LOS, referrals, readmissions, denial rates, cost savings, patient/provider satisfaction and achievement of outcomes.
• Serve as a liaison to other agencies, departments, or community resources as needed to coordinate care in transition planning.
• Participate in required educational programs and actively demonstrate self-directed learning and continuing education to enhance professional development in the area of case management.
• Participate in staff development activities and staff meetings.
• Identify and refer to manager and supervisor all cases involving complex medical issues for review.
• Record, monitor and report data such as clinical outcomes achieved, potentially avoidable and medically necessary variances, denials, length of stay, reviews completed and outcomes (savings and referrals), and discharge dispositions on a daily basis.
• Work with the attending physician, hospitalists/rounders, specialists, hospital and social work staff to create an actionable plan of care and transition / discharge plan for each patient followed, as needed.
• Demonstrate knowledge regarding transition criteria and level of care and use of appropriate community-based resources.
• Review and assesses inpatient cases for eligibility, benefits and limits, medical necessity and ongoing appropriate level of care.
• Function independently and as part of a team, working effectively with various departments, internal and external staff, facilities, patients, patients’ family, and physicians to facilitate quality and efficient patient care.
• Perform other duties as assigned.

REQUIRED QUALIFICATIONS :

• Registered Nurse with current unrestricted license in the State of California, BSN preferred. License free of history of restrictions and/or sanctions in the past 5 years in all states with current or past licensure.
• Minimum 3 years’ experience as a Registered Nurse in a clinical setting, performing utilization review, case management or discharge planning
• Excellent verbal, written and interpersonal skills

Job Type: Full-time

JOB DESCRIPTION: This position requires a goal-oriented, revenue-driven, highly accurate and motivated Biller. Primary duties include, but are not limited to: consistently follow up on unpaid claims utilizing monthly aging reports, filing appeals when appropriate to obtain maximum reimbursement and establish and maintain strong relationships with providers, clients, patients and fellow staff. Secondary duties include but are not limited to: data entry of all patient demographic, guarantor and insurance information, posting procedures and insurance/patient payments, balance to daily deposits and other duties as assigned.

Responsible To: Billing Manager
REQUIRED SKILLS

• Computer experience is essential, including, but not limited to: Eclinical software, word processing and spreadsheet applications, with a minimum of 40 wpm typing speed and 10-key by touch.
• Experience in CPT and ICD-9 coding; familiarity with medical terminology.
• Advanced experience in all aspects of revenue cycle management.
• Excellent customer service skills.
• Strong written and verbal communication skills.
• Ability to manage relationships with various Insurance payers.
• Experience in filing claim appeals with insurance companies to ensure maximum entitled reimbursement
• Neat appearance; pleasant speaking voice and demeanor; positive attitude.
• Responsible use of confidential information.
• Perform to company standards of compliance with policies and procedures.
• Ability to multi-task and work courteously and respectfully with fellow employees, clients and patients.

DETAILED WORK ACTIVITIES

• Ensure all claims are submitted with a goal of zero errors.
• Verifies completeness and accuracy of all claims prior to submission.
• Accurately Post all insurance payments by line item.
• Timely follow up on insurance claim denials, exceptions or exclusions.
• Meet deadlines.
• Reading and interpreting insurance explanation of benefits.
• Utilize monthly aging accounts receivable reports to follow up on unpaid claims aged over 30 days.
• Make necessary arrangements for medical records requests, completion of additional information requests, etc. as requested by insurance companies.
• Respond to inquiries from insurance companies, patients and providers.
• Perform and/or assist in month end procedures for accurate accounting.
• Regularly meet with Account Manager to discuss and resolve reimbursement issues or billing obstacles.
• Regularly attend monthly staff meetings and continuing educational sessions as requested.
• Perform additional duties as requested by Supervisory or Management team.

REQUIRED EDUCATION.
High School diploma or equivalent. Prefer Associates degree in Medical Billing and Coding or Accounting; however, four years of experience in lieu of education may also be considered.

JOB DETAILS & BENEFITS
Job Location: Bakersfield, CA 93309
Hours/Week: Full-Time 40 Hrs per Week (8:00 AM – 5:00 PM) Monday-Friday *flexible Benefits
Include: Medical, Dental & Vision Insurance, Holidays & Paid Time Off

Job Duties:

• Data Entry – bank transactions, deposits, journal entries.
• Reconcile Bank Accounts, Credit Cards.
• Creating Invoice and POs
• Accurate invoice coding to proper GL accounts.
• Investigate invoice discrepancies.
• Accounts Payable functions.
• Match checks to the corresponding invoices paid.
• Expense classification.
• Print and mail checks.
• File invoices and maintain organized vendor files.
• Reconcile monthly vendor statements.
• Maintain 1099 vendor file and prepare annual Form 1099s.
• Reconcile accounts payable related GL accounts.
• Handle accounts payable inquiries from internal customers and external vendors.
• Support the monthly financial close process.
• Prepare journal entries and account reconciliations as part of monthly close process.
• Daily filing along with responsibility for department files (organization, maintenance, creation of new files, etc.).
• Respond to requests from external auditors.
• Other duties as assigned

Requirements:

• AA degree or equivalent in Bookkeeping/ Accounting
• 4+ years in Bookkeeping/Accounting
• QuickBooks experience a Must
• Healthcare experience in Accounting is a plus!
• Strong math and analytical skills
• Proficient in Microsoft Excel.
• Experience and Strong Knowledge of accounting principles: A/P, A/R, general ledger, Financial Statement preparation and analysis, account analysis, reconciliations.