Job Description

Come and join the RMC Family! 

We have been in the community since 1935.  Our mission is to provide comprehensive multi-specialty medical services in the greater Riverside region.  Your passion, inspiration, and talents are invaluable to us and our mission to serve others.  Our facility can provide a place for you to thrive and continue your professional development.  Quality Healthcare is our passion, improving lives is our reward.  We are working to change lives and transform the delivery of healthcare. Riverside Medical Clinic is the best place to work, practice medicine, and receive care.

Summary: To provide timely and accurate claims status information to providers, members, health plans, or other customers in need of assistance. Act as liaison between providers, HMO’s, members and the claims unit in order to establish and maintain professional relationships between all parties. Update HMO member coverage records in the Epic system based on the monthly encounter error report.

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 the essential functions. Must have knowledge using Microsoft Word, Excel and Access software programs

Education and Experience: High school diploma or general education degree (GED); or 2 or more year’s claims processing experience and/or training; or equivalent combination of education and experience. 

Certificates, licenses and registrations: None. 

ESEssential Functions:

Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job’s purpose and objectives.  Essential functions are critical or fundamental to the performance of the job.   They are the major functions for which the person in the job is held accountable.  Note:  (other duties may be assigned, deleted or changed at any time, at the discretion of management, formally, or informally, either verbally or in writing).

1. Uphold and support the philosophy, objectives, Code of Conduct and policies of Riverside Medical Clinic.

1. Assume responsibility for initiating a pleasant service-oriented atmosphere by displaying a professional attitude through performance, appearance, and demeanor.

1. Maintain work area in a clean and orderly manner.

1. When messages from providers, patients or health plans are left on the customer service audix the calls will be returned within 48 hours of receipt.

1. When speaking with a customer, should additional information or research required to be able to give a correct response to the customer, inform the caller you will return their call with the information within 48 hours of receipt. Schedule the return call directly on the calendar in Outlook.

1. Document all claim inquiry calls coming in to Tapestry in CRM for call tracking and follow up

1. Sort claim inquiries in order of priority and submit them to the Claims Supervisor for review. The Supervisor will determine the level of priority processing and forward appropriately.

1. Act as liaison between the providers, HMO’s, members and claims unit in order to establish and maintain professional relationships between all parties.

1. If the claim was processed before and the caller is appealing the original decision, this is not a dispute it is a “claim inquiry”, and the claim will be handled as a priority, and forwarded to the Claim Supervisor.

1. If a provider states they previously sent in a written dispute, there will be notes in the claim system identifying it as such. Only then will the Provider Dispute Auditor become involved and address the concern directly with the caller.

1. When claims cannot be processed or completed due to missing information, request additional information from providers, when needed.

1. Calendar for follow up on all customer service claims forwarded to the examiner to ensure they are processed in accordance with regulatory and departmental requirements. As a courtesy to the provider contact will be made notifying them of the decision.

1. Verify the patient accounts, eligibility and authorizations were correct when original claims were processed. Determine if a balance due or denial is required and communicate this to the Claims Supervisor and/or Provider Dispute Auditor.

1. Prepare and print provider labels for mailing zero payment EOB’s to providers receiving a denial or request for resubmission of a corrected claim. EOB’s are to be mailed before the close of business every Friday afternoon.

1. As a back-up to the clerk, will assist the Director with preparation of documentation, claims, acknowledgements, EOB’s, checks, denial letters and Provider Disputes for HMO Health Plan claim audits, as needed.

1. Other duties as assigned by management .

This opportunity offers the following:

Challenging and rewarding work environment
Growth and Development Opportunities within UHS and its Subsidiaries
Competitive Compensation

About Universal Health Services

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

Avoid and Report Recruitment Scams

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.

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