Job description

People are the most important asset of Imperial, for this reason the difference and plurality of people, equality of opportunities, non-discrimination and inclusion in the workplace are priority and strategic factors in the Organization. Imperial maintains a strong will to promote Diversity, Equity, and Inclusion, through inclusive leadership as a lever change and business sustainability.

Imperial Health Plan of California, Inc. is approved by California Department of Managed Health Care to offer full-service Medicare Advantage coverage, including a Medicare Advantage Prescription Drug plan, and a Chronic Condition Special needs plan over numerous counties in California. Through its affiliate, Imperial Insurance Companies, Imperial also offers Medicare Advantage plans in Texas, New Mexico, Utah, and Arizona.

Our Mission: To deliver valuable care so that members are healthy in body, mind, and spirit to achieve their inherent potential.

Our Vision: To deliver value based care that is clinically effective, sustainable, and achieves exceptional outcome.

JOB SUMMARY: Oversee the performance, productivity, and quality of the medical review staff. Will evaluate medical claims review processes and be accountable for the operations and delivery of a best-practice HIM service model. Manages a comprehensive medical claim review and medical underwriting processes. Manages the collection of medical information and the professional clinical review, interpretation, and criteria to determine if claims are eligible for payment or if the applicant meets criteria for medical coverage.

ESSENTIAL JOB FUNCTIONS:

1. Obtain signatures and provide requested records to approved personnel.

2. Follow HIPAA guidelines and ensures confidentiality of PIH.

3. Process requests for records in a timely manner.

4. Manages the implementation and monitoring of operational, administrative and regulatory compliant requirements for medical claim and medical underwriting review.

5. Acts as a professional resource for matters concerning criteria for coverage, accurate claim processing, complex pricing methodologies for medical care, and medical underwriting criteria. These requirements include high levels of production in short timeframes, as well as quality review.

6. Ensures comprehensive responses to inquires regarding complex claims and medical underwriting.

7. Manages the development, modification and evaluation of existing medical claim review and medical underwriting programs to create a uniform and compliant process.

8. Manages and monitors complicated medical reviews and medical underwriting assessments.

9. Ensures that written communication of the subsequent decisions are compliant with contract and regulatory requirements.

10. Develops, implements and monitors performance standards and documentation to ensure compliance with NCQA, State and Federal requirements for all functions within the scope of this position.

11. Ensures that all acute health record processing related services and strategic goals are aligned with organizational priorities and developed in a consistent and standardized manner.

POSITION REQUIREMENTS:

EDUCATION/EXPERIENCE:

· Bachelor's Degree in Health Administration, nursing, or a related field or equivalent education/experience

· 4 years experience in managed care, claims processing, and/or medical underwriting; medical surgical experience

· 4 years of Leadership role in HIM in a healthcare environment such as a health plan or hospital

SKILLS/KNOWLEDGE/ABILITY:

· Prior NCQA, URAC experience including knowledge of accreditation standards and requirements

· Extensive knowledge of NCQA/URAC requirements of utilization review, experience working with statistical information, member’s right to appeal, medical underwriting principles

· Willingness and ability to read, write, speak, understand English and have the communications skills necessary to provide accurate information to members and staff.

LICENSURE/CERTIFICATE/TRAINING:

· Certification in Medical Claims Coding preferred

Job Type: Full-time

Pay: $110,000.00 - $120,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift

Ability to commute/relocate:

• Pasadena, CA: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Medical records: 4 years (Required)

Work Location: In person

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