COMPLIANCE ANALYST - Full Time

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: Maintaining compliance with regulatory requirements as governed by RMC and the health plans. Responsible for supporting the Claims Department Manager/Supervisor with reviewing and analyzing various reports and data. Maintaining compliance with regulatory requirements with CMS and DMHC. Ensure compliance with timeliness in decisions, initial notifications for compliance to health plans. Ensure department adherence and compliance with process and procedures.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential function 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.

EDUCATION and/or EXPERIENCE: High school diploma or general education degree (GED); or one to three months related experience and/or training; or equivalent combination of education and experience. Working knowledge of medical insurance and coding. Proficient in excel and word. Possess excellent organizational and communication skills.

CERTIFICATES, LICENSES, AND REGISTRATIONS: None.

ESSENTIAL 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.Maintain denial templates with current updates mandated by CMS Center for Medicare and Medicaid Services (CMS) and Department of Managed Health Care (DHMC).
2.Communicate all updates with Claims Department Manager and support staff to ensure compliance with CMS and DMHC regulatory guidelines on timeliness, standard and expedited.
3.Assist the Claims Department's Manager with a variety of standard monthly audits.
4.Monitor and ensure adherence and compliance with the Claims department process and procedures.
5.Monitor the scheduled audit list and adhere to deadlines.
6.Assist with the Provider Dispute Resolution if the dispute is regarding a payment error, research and analyze the payment methodology in which the claim was adjudicated.
7.Ensure all Provider Disputes are processed in accordance with the timelines outlined in AD 1455 and the DMMC regulatory requirements.
8.If the dispute is Contract issue, research contracts to be ensure the claim was adjudicated correctly if disputed.
9.Research and process all provider appeals received for senior health plan member claims within 30 days from receipt. overpayments, and request refunds
10.Prepare monthly reports and analyze miscellaneous data. Research health plan demand letters and overpayments to providers. Request refunds as necessary.

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. www.uhs.com

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.