To direct, empower, and lead operational departments such as Claims and Customer Service in meeting all of the objectives and compliance goals. To maintain in strict confidence, all MRG/HPN, member, provider and Health Plan information to which Vice President of Operations has access.

Essential Duties and Responsibilities include the following:

• Coordinate the development of, and oversee the execution of Claims, Customer Service, Human Resources and Facility/Mailroom operations to ensure adherence to all contractual and regulatory requirements.
• Perform the administrative functions such as departmental budgets, financial planning and staff projections.
• Oversee the training and resource material as needed.
• Oversee the development of Policy and Procedures for Department as needed.
• Support company activities such as company goals/strategy and management meetings as required.
• Interpret the contracts and claims for the appropriate payment and benefit determination.
• Create and run reports for department oversight, and compliance issues.
• Represent the Claims Department in Operation, Committee and health plan Meetings.
• Oversee the Health Plan and regulatory audits, and represent Claims in all audit processes.
• Keep senior executive staff informed of operational activities.
• Develop reports for internal and external reporting needs.
• Responsible for meeting or exceeding established departmental goals such as production standards, compliance, and claims accuracy.
• Evaluate staff as part of interview or review process and make recommendations for employee hiring, firing, and/or retention.
• Other duties as assigned.

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)

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Paid Time Off (PTO)
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• 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.

Education and/or Experience:

• Bachelors or 5+ years working knowledge of claims processing and customer service operations.

• Strong Call Center Management experience required.

• Extensive experience in managing large claims staff, with multiple health plans, products and regions.

• Excellent professional and hospital claims adjudication skills.

• Full working knowledge of TPL, COB, PPO, POS, HMO, ASO and Indemnity products.

• Knowledge of DRG Grouper.

• Knowledge of CPT-4, HCPCS, Revenue and ICD-9 coding.

• Extensive knowledge of Medicare, and Medi-Cal.

• Knowledge of contracts and contractual interpretations for payment and benefit issues.

• Strong knowledge of Microsoft Windows environment.

• Working knowledge of Microsoft Excel and Word.

• Excellent written and verbal communication skills.

• Strong organizational and leadership skills.

• Experience developing and producing management reports.

• EZ-Cap experience helpful.