Job Description

Location: Novato, CA

Employment Status: Full Time

As a key member of the Network Relations Department, serves as the primary point of contact for all incoming calls and inquiries to the department. Provides administrative support to the Network Liaisons while they are out in the field visiting provider offices or are otherwise occupied with meetings and events.  Assists with coordinating quarterly physician and network-wide newsletters and ad hoc communications with the provider offices. Assists with the coordination of Network events and meetings.  Sets up and maintains network department databases, files and records.

Responsible for all aspects of the credentialing, re-credentialing and privileging processes for all medical providers in Meritage Medical Network.  Responsible for ensuring providers are credentialed, appointed, and privileged with contracted health plans, and National Committee for Quality Assurance (NCQA) requirements. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications.  Works to develop and maintain a streamlined, efficient and automated process for credentialing and re-credentialing. Works closely with other Meritage staff (e.g., Claims and Utilization Review department staff), to update provider agreements in the Meritage database (Quickcap).

1. Maintains a sound and comprehensive understanding of the Network Relations department and staff in order to assist internal and external customers to the department with service and information requests.
2. Maintains a solid understanding of the Meritage Medical Network organization, services and staff and how such services and personnel support network physicians and practices.
3. Answers department telephones, responds to general inquiries, takes messages and refers calls/inquiries to the appropriate Network Liaison, and/or refers calls as necessary to other Meritage staff/departments.
4. Assists with the development of physician and office staff information and education materials for distribution in the field, including the Network Quarterly newsletter, to physician practices.
5. Assists with the coordination of Regional Operations Committees and Membership Committee meetings, including but not limited to developing and maintaining committee lists, developing and sending out invitations, save the date reminders, reserving meeting locations, meal coordination, developing and disseminating meeting agendas and materials, and maintaining associated records and databases.
6. Responsible for all aspects of credentialing/re-credentialing providers, to include but not limited to verification of application/documents, mailing of requests for consideration, initial applications, approval, denial, termination letters, tracking license and certification expiration for providers, and accurately loading/maintaining provider information into the Credentialing database.
7. Prepares credentialing files and monthly matrices for presentation to the Membership Committee; responsible for confirming the completeness of information and all documentation prior to presentation.
8. Maintains all of the credentialing documentation up to health plan audit standards and coordinates with health plans for annual credentialing audits.
9. Maintains knowledge of current health plan and network requirements for credentialing
10. Develops, maintains and provides reports from the department database and prepares custom reports, data searches and/or data analysis in response to specific requests by internal and external customers.
11. Audits health plan directories for current and accurate provider
12. Performs other duties as assigned related to supporting the Network Relations Department and the overall Meritage organization.

Job Requirements

1. Excellent customer services skills with a demonstrated genuine and friendly demeanor.
2. Strong written and verbal communications skills.
3. Detail orientation with the ability to organize and prioritize work and manage multiple priorities with mature judgement.
4. Ability to multi-task and meet deadlines and agreed upon deliverables.
5. Ability to problem solve and research and analyze data, discrepancies and variances.
6. Professional comportment and work style that projects a confident, open, capable and trustworthy persona that is able to be sustained and maintained in all initial and subsequent interactions with customers.
7. Must possess strong listening skills with the ability to make customers feel as though they have been heard and that their input, concerns and suggestions are valued and will be taken seriously.
8. Demonstrated ability to work and communicate efficiently and effectively with physicians and their staff on credentialing matters.
9. Must be a self-starter with the ability to work independently with minimal
10. Working knowledge and experience with office based computer equipment and systems including but not limited to: Word, Excel, PowerPoint, Outlook, Adobe and Publisher.
11. 1-3 years’ related work experience, with a minimum of 2 years of current credentialing work experience, preferably in a managed care setting.
12. Bachelor’s degree in a related healthcare or business field preferred.

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Job Description

Location: Novato, CA

Employment Status: Full-Time

The Utilization Management Coordinator serves as a liaison between Meritage Medical Network, our contracted health plans, Network physicians and Members. The incumbent will serve as a resource to other UM team members and is responsible for processing authorizations within the scope of their assignment. This position reports directly to the UM Manager.

Principle Duties and Responsibilities:

• Utilize knowledge and experience to analyze contractual or administrative issues related to the requests.
• Identify additional information needed and ability to research and understand Policy benefits and criteria
• Accurately identify when and how to refer cases to appropriate clinical personnel or take other actions as necessary or required.
• Follow strict guidelines to ensure all work meets ICE standards for accuracy, timeliness, quality and compliance with federal, state and accreditation regulations.
• Coordinate with other insurance coordinators and the medical review staff.
• Consistently meet department productivity and performance metrics.
• Contribute to the efficiency of the department by being flexible and cross-trained on other functions.

Job Requirements

Minimum Qualifications:

• Two years of current related Utilization Management experience required; Managed Care or health plan experience strongly preferred
• Medical Assistant certificate preferred and additional relevant work experience will be considered.
• Must have the ability to understand and use set criteria within the related UM system.
• Familiarity with insurance billing and medical terminology
• Knowledge of CPT/ICD-10 codes.
• Excellent interpersonal skills, including phone, verbal, and written communication.
• Ability to cope in a fast-paced production environment
• Demonstrated knowledge of customer service skills when responding to questions and other inquiries from internal and external customers.
• Strong computer skills with demonstrated proficiency in word processing, spreadsheet, database, presentation and email applications.
• Must be organized and detail oriented

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Job Description

Location: Novato, CA

Employment Status: Full Time

Position Summary

The Human Resources Generalist performs a variety of Human Resources functions which include but are not limited to all aspects of Recruitment and on-boarding of new staff, Health & Welfare Benefits and Retirement Plan administration, and HRIS maintenance.  Also performs a variety of HR related employee recognition, relations, staff development and internal communications assignments and projects.  Works as part of a cohesive HR team, in close partnership with Meritage leadership who have open positions, and with the Accounting/Payroll department for issues associated with employee assignments, pay and benefits, and other job status/classification matters.  Works as an effective, collegial, and trusted partner to all Meritage staff, external partners (i.e. insurance carriers, brokers, advisors, etc.), and inter-disciplinary work teams.

Essential Job Duties

1. Assists the other members of the Human Resources team with daily workflow, operations, planning and prioritization of work, and project work associated with the department.
2. Supports the Chief Administrative Officer as required to support various HR and related functional area initiatives.
3. Responsible for employee recruitment activities for all level positions. This includes: clarifying content and requirements for open positions, updating Job Descriptions, posting jobs on the Meritage website and identified external posting and advertising sites, sourcing candidates (e.g. staff referrals, LinkedIn, etc.), screening applicants, forwarding candidates for management review, coordinating interview processes, obtaining references, assisting with negotiating employment offers, extending offers, and obtaining background screenings.
4. On-boards new employees, exits terminating employees, and tracks exit interview feedback and reports trends and findings as required.
5. Responsible for intake, response to and follow-up of EDD data requests for employees accessing SDI benefits and following termination of employment.
6. Responsible for organizing and maintaining applicant databases, tracks status of openings, and develops, tracks and reports recruitment and hiring metrics.
7. Understands and communicates company benefits programs, including Retirement Plan, and company mission and values.
8. Assists with the planning, development and drafting of materials and processes associated with annual Benefits Open Enrollment. Assists with annual benefits fairs by working closely with HR team members, health plan brokers and benefits carriers.
9. Assists with the coordination and tracking of all aspects of staff Leaves of Absences, consistent with FMLA, CFRA, ADA, and all other regulatory laws, rules, and requirements.
10. Utilizes the company HRIS and assists with input and regular audit of employee data – demographics, assignment, and benefits data. Maintains excellent working knowledge of the HRIS and continues to develop more advanced skills in this area.
11. Updates employee electronic files and databases to document personnel actions and to provide information for payroll and other uses.
12. Works closely with and acts as primary back up for the Senior HR Generalist and assumes assigned duties in their absence.
13. Is accountable for work performed, works to develop, and maintain trusting working relationships with Meritage staff, HR co-workers, leadership, and external business partners.
14. Seeks to continuously learn from errors and experiences, as well as new developments in job specific HR areas, and actively applies continuous performance improvement methods to workflows and processes.
15. Performs other than normally assigned duties, as required, within and outside of the HR department to support Meritage’s business needs.
16. Adopts, incorporates, is mindful of, and otherwise supports Meritage’s overarching annual and longer-term business goals and objectives while performing regular job responsibilities, special projects and other duties as assigned.
17. Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and seeks to influence these behaviors in others.
18. Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and
19. Initially and on an ongoing periodic basis, spends time with each HR staff member, payroll and other identified internal staff to gain an understanding of their job duties, challenges, and to better identify and support an effective continuum of workflow with Meritage, to support continuous process improvement and remove any roadblocks impacting productivity.

Job Requirements

Minimum Requirements:

1. A Bachelor’s Degree in Human Resources or related field.
2. A minimum of 2-3 years of current directly related HR experience, preferably in Healthcare.
3. Or, an equivalent combination of education, work experience, and skills (see below).
4. HR Certification is preferred

Knowledge and Skills:

• Strong working knowledge of updating, maintaining, auditing, and developing an HRIS system, including  reporting capabilities for report generation.
• Current understanding of State and Federal laws and regulations related to fair and lawful interviewing and hiring processes, Section 125 Health and Welfare plans, Leaves of Absence, 401(k) retirement plans, At-Will employment arrangements and related progressive disciplinary actions and processes, and termination actions.
• Strong skills and working experience with Excel, PowerPoint, Publisher, and Word.
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratios, and percentages.
• Excellent written, verbal and listening communication skills, with the ability to conduct presentations over Microsoft Teams, Zoom and in person.
• Professional demeanor with a positive and self-confident, yet approachable and kind, affect.
• Ability to exercise cognitive thinking skills and to work independently with minimal supervision.
• Ability to develop, draft, update and communicate policies and procedures.
• Demonstrated ability to work in a fast-paced environment with rapidly changing and competing priorities.
• Take initiative and determines best course of action for a vast array of HR issues by accessing all available resources.

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Job Description

Location: California-remote

Employment Status: Full Time

The Claims Auditor is responsible for auditing adjudicated claims for accuracy of payments and denials. Knowledge of all claims procedures, claim types (facility, professional, ancillary), different pricing methodology are essential. Ensure claims compliance in all areas. Prepares and maintains audit reports.

Key Responsibilities

• Conducts audit and quality control of adjudicated claims for accuracy in amount paid/denied, appropriate use of claim adjustment codes, payment explanation, correct provider and vendor selection.
• Follows established policies and procedures and use available resources such as provider contracts, Medi-Cal and Member Evidence of Coverage (EOC) to process, and adjust routine assigned claims in an accurate and timely manner.
• Identifies root cause of errors such as processing or claims system configuration Prepares and submits audit reports which include audit findings, scores and corrective actions.
• Monitors completion of corrective actions
• Provides timely feedback to management.
• Maintains a current working knowledge of all claims regulatory requirements for Medicare and Medi-Cal claims
• Conducts training as necessary.
• Assists in the reconciliation and review of claims related issues.
• Collaborates with peers, staff in other departments vendors, and Management to improve processes and department work quality
• Attends and actively participates in daily, weekly, and monthly departmental meetings, training and coaching sessions.
• Organizes and maintain all audit files
• Other related duties as assigned.

Job Requirements

• High school diploma or equivalent.
• College degree preferred
• A minimum of five years of Medi-Cal and Medicare claims processing experience and/or combine of education and experience
• Knowledge of medical terminology, ICD-9/ICD-10, CPT and DRG coding, required.
• A minimum of two years experience in a managed care organization, preferred.
• Excellent knowledge of claims systems.
• Ability to demonstrate organizational skills with a high attention to detail as well as strong verbal and written communication skills.
• Ability to maintain designated production and quality standards.
• Knowledge of different providers’ payment methodologies (i.e., capitation, fee for service based on RBRVS, Medicaid and other negotiated flat rates, RVS pricing, Per Diem, DRG pricing, etc.), preferred.
• Ability to deal with complex claim issues.
• Knowledge of Medicare and Medicaid claims processing guidelines, Title 28 Claims Settlement Practices and other regulatory requirements.
• Proficient with Microsoft Office programs including PowerPoint, Outlook, Word, Excel and common computer equipment and office hardware.
• Strong analytical skills
• Ability to calculate audit scores using different formulas
• Ability to complete tasks in a timely manner.
• Ability to communicate effectively both verbally and in writing.
• Ability to work in a fast pace environment with minimal supervision

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Job Description

Location: Novato, CA

Employment Status: Full Time

The Network Relations Coordinator is responsible for performing numerous clerical and coordination support functions within the Network Relations Department.  A strong focus will be on database maintenance, including initial set-up and entry of data elements, data imports, as well as ongoing maintenance and regular auditing of information maintained in multiple systems.  Will work on various Network and Provider lists, rosters, fee schedules, contract templates, and related records and documents. Accountable for the integrity and quality of data maintained and works to resolve discrepancies through collaboration with co-workers and customers within and outside of the Network Relations department.

SUMMARY OF RESPONSIBILITIES

• Processes network updates such as Adds/Terms/Changes related to demographic and contract conversions via a work queue assignment.
• Audits and tests demographic and/or fee schedule imports based on work queue assignment.
• Researches and resolves issues regarding provider data, fee schedules, configuration, originating from various departments and conversion audits.
• Provides on-going database cleanup through various reports, research and outreach via email and phone calls.
• Responsible for the maintenance and verification of physician rosters, and roster reconciliations
• Ensures prompt and accurate data entry into various departmental systems, databases, and company systems, Quick Cap C7, including tasks in the queue.
• Maintains organization of files on departmental shared drives, assigned systems and databases to ensure such information is up-to-date and easily accessible.
• Consistently meets department productivity, efficiency and performance metrics, goals, and objectives. Recommend process, practice and procedural changes and improvement to streamline, simplify and strengthen department efficiencies in assigned areas.
• Contributes to the efficiency of the department by being flexible and cross-trained on other functions and positions.
• Assists in the gathering, coordinating, and reporting of Network department data, including reports to health plans, regulatory agencies, Network Providers, and other internal and external parties.

• Is accountable for work performed, works to develop, and maintain trusting working relationships with Meritage staff, co-workers, leadership, and external business partners, e.g. Health Plan and physician office representatives.
• Seeks to continuously learn from errors and experiences, as well as new developments in job specific areas, and actively applies continuous performance improvement methods to workflows and processes.
• Performs other than normally assigned duties, as required, within and outside of home department to support Meritage’s business needs.

• Adopts, incorporates, is mindful of, and otherwise supports Meritage’s overarching annual and longer-term business goals and objectives while performing regular job responsibilities, special projects and other duties as assigned.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and seeks to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and
• Initially and on an ongoing periodic basis, spends time with (i.e. “shadows”), staff in other departments to gain an understanding of their job duties, challenges, and to better identify and support an effective continuum of workflow within Meritage, and remove any roadblocks impacting productivity.

Job Requirements

Competencies

• Knowledge of MS Office and related applications.
• Demonstrates the ability to learn and utilize Quick Cap proprietary systems.
• Manage data received in various formats from various sources
• Processes provider updates efficiently and accurately
• Proficient knowledge of MS Access and Excel.
• Proficient knowledge of relational databases.
• Familiar with provider data elements, provider contracts, claims logic and provider matching.
• Managed Care experience preferred but not required

MINIMUM REQUIREMENTS

• Bachelor’s Degree with two (2) or three (3) years related experience and/or training or equivalent combination of education and experience
• Strong detail orientation and organizational skills.
• Effective written, verbal and listening communication skills.
• Ability to learn and utilize company systems, i.e., Quick Cap
• Proficient with MS Office (Word, Excel and Access), Outlook and Internet, FTP sites and downloading of files.

WORK ENVIRONMENT

• Self-motivated and able to work independently and as part of a team, but also to know when to ask for help from co-workers and supervisor.
• Required to handle and balance multiple priorities from various service areas.
• Fast pace work environment.
• Able to solve problems and take initiative.

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Job Description

Location: California-Remote

Employment Status: Full Time

General Summary

The Accounts Payable Specialist is responsible for processing high-volume, full-cycle Accounts Payable, including check runs, vendor communications, and maintenance of accurate accounts payable records.  As needed, the Specialist provides general accounting back-up to support other department needs.

Essential Job Responsibilities:

• Organizes, codes and processes company invoices following established procedures
• Ensures invoices have proper back-up and approval for payment
• Inputs invoices into accounting system
• Prepares the monthly AP Accruals
• Prints batches and reviews them for accuracy (document date, GL code, vendor ID, vendor address, and amount)
• Prepares checks to be mailed and/or otherwise distributed
• Audits work to ensure there are no duplicate payments, late payments, mis-coded invoices, and over-payments
• Checks and verifies vendor information for accuracy
• Communicates with vendors about past due payments, account inquiries, missing invoices, etc.
• Reconciles company credit card statements to invoices/receipts from card holders
• Researches and resolves issues associated with outstanding and lost checks
• Assists with vendor and payment analysis; creates and generates reports as needed
• Assists in the preparation and distribution of 1099s and management of W-9 records
• Performs other duties and responsibilities as assigned, including support for other departments based on volume, projects and company work priorities

Job Requirements

Required Education, Experience and Skills

• Associate Degree or college-level coursework in Accounting, Business or related field with a minimum 2-3 years’ related work experience; or an equivalent combination of education and experience
• Prior healthcare experience is a bonus
• Strong skills in Microsoft Office, especially Excel
• Experience with accounting software, Great Plains is a plus
• Excellent basic math skills
• Strong organizational skills, attention to detail and proven experience meeting deadlines
• Demonstrated customer service focus with a positive and respectful work style and professional business demeanor
• Strong written, verbal and listening skills with the ability to make customers feel as though they have been heard and that their input, concerns and suggestions are valued and will be taken seriously

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Job Description

Location: California-remote

Employment Status: Full Time

The Customer Service Representative communicates with a diverse constituency of internal and external customers and responds to individual questions and concerns specific to organizational determinations, claims, plan benefits, coverage determinations, disputes, and questions or issues related to payment methodology. Receives and responds to calls from providers and members. Transfers calls as necessary to applicable department, such as, but not limited to, utilization management, or to applicable Health Plan as appropriate. Conducts inquiries and research related to provider and member questions and concerns, including claims and authorization status and related information, and documents all calls and responses.  Relays plan contact information to providers and members as applicable and appropriate.

Essential Job Functions:

• Receives inbound calls and responds appropriately to provider, member, health plan, or other caller’s questions and/or concerns.
• Answers calls timely and in accordance with the performance standards established within the customer service department.
• Provides information as requested related to coverage determinations and appeals processes.
• Provides information as requested by caller related to eligibility, benefits, claims and authorizations status inquiries.
• Facilitates provider and member communications related to network providers.
• Responds to provider dispute queries.
• Provides plan contact information as applicable to members and providers.
• Maintains applicable and timely records and files regarding member and provider communications and service coordination.
• Reviews all documents received for completeness
• Verifies claims status and coordinates information, as applicable, with provider and claims staff.
• Forwards calls as appropriate to supervisor or other staff for further response or follow up.
• Ensures confidentiality of all hard copy, electronic, and verbal communication, and adheres to organization’s policies related to privacy and disclosure.
• Promotes a positive image of the organization and the department in all aspects of communication and contact.
• Performs other duties as assigned.

Job Requirements

Minimum Experience and Qualifications

• Previous experience in Customer/Member services or related function in health care organization preferred.
• Experience in a managed care environment preferred.
• Demonstrated experience and expertise in customer service skills: excellent verbal and written communication skills, handling difficult communications with skill to achieve positive outcome, clear and concise targeted communications focused on the customer (verbiage, language, style, etc. all may vary depending on the customer/audience).
• Bilingual (English/Spanish) preferred
• Knowledge of claim benefit interpretation/benefit adjudication logic
• Demonstrate proficiency in medical terminology and coding (ICD10, CPT, UB04)
• High school diploma.  Some college level course work preferred.

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Job Description

Location: Novato, CA

Employment Status: Full Time

Position Summary:

This position is responsible for providing routine and clerical support to the  Utilization Management (UM)  department. Duties and responsibilities include but are not limited to:

• Open, sort, scan, compile, distribute and archive, as appropriate, both paper and electronic mail, forms, faxes, reports and other general documentation within the area(s).
• Prepare, compile, print, organize and facilitate area mailings, including but not limited to, Authorization, Denial and Pend Letters.
• Audit Authorizations for correct addresses and communicate address issues to the eligibility department and process requests for reprints.
• Ensure prompt, accurate data entry of UM related documentation, requests and data into the various department and organizational information systems and databases.
• Consistently meet department productivity and performance metrics, goals and objectives.
• Contribute to the efficiency of the department(s) by being flexible and cross-trained on other functions.
• Performs other clerical and administrative support duties and functions as assigned.

Job Requirements

Qualifications and Requirements:

• High School diploma.
• Strong written and verbal communications skills, including effective listening skills.
• Demonstrates a strong customer service orientation, including a professional and respectful demeanor with customers, co-workers and other business partners
• Treats others with respect, kindness and patience.
• Excellent organizational and prioritization skills.
• Ability to work independently as well as collaboratively and effectively with others, as part of a team.
• Basic knowledge of Microsoft office products.
• Ability to work with and maintain confidential information and comply with HIPAA requirements.
• 1-3 years of previous experience in a fast-paced healthcare related environment with production requirements, managed care experience preferred.
• Proficiency in medical terminology, Utilization Management and Quality processes and procedures.
• Familiarity with personal computers including demonstrated navigational skills in a Windows environment and proficient keyboarding skills.

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Job Description

Location: Novato, CA

Employment Status: Full Time

Position Summary:

The Utilization Management (UM) Nurse is responsible for general, preauthorization and/or retrospective review of outpatient services and for the determination of medical appropriateness and medical necessity for a variety of services using evidence-based clinical guidelines and works with providers to meet the health care needs of members with the appropriate resources.

• Performs prior authorization and retrospective review according to evidence-based clinical criteria, Medicare Guidelines, and established protocols to determine the medical appropriateness of the request.
• Refers cases to the Medical Director, Utilization Management when the treatment request does not meet medical necessity guidelines or when peer-to-peer conversation is necessary.
• Makes referrals to the Medical Director, Utilization Management in a timely manner, to allow time to make appropriate contact with the requesting provider is accordance with State, Federal, Regulatory, and accreditation turnaround times.
• Maintains a thorough understanding of NCQA, URAC, and CMS guidelines for Utilization Management.
• Communicates with members of the Utilization and Care Management team, reviews medical records, uses clinical expertise, and compares information to established guidelines and the member’s benefit plan.

Job Requirements

Required Qualifications:

1. Ability to be a team player and exercise initiative in responding to provider requests and concerns in a helpful and courteous manner
2. Provider contracting and customer service techniques
3. General understanding of the health care industry, ideally the provider relations field-desired
4. Excellent interpersonal and telephone communication skills are required
5. Exercise attention to detail; ability to provide accurate data entry
6. Ability to work under pressure with minimal supervision, multi-task, complete projects in a timely fashion and meet deadlines a must
7. Excellent analytical, problem solving and organizational skills a must.
8. Language Skills: Strong communication skills both written and verbal to work with multiple internal and external clients
9. Mathematical Skills: Ability to work with mathematical concepts such as probability and statistical inference. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations
10. Reasoning Ability: Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems.
11. Computer Skills: Ability to create and maintain documents using Microsoft Office (Word, Excel, Outlook, PowerPoint)

Minimum Experience

• 3+ years of experience clinical experience in an acute care facility or equivalent combination of education and experience
• 3 years experience working in Managed Care. Medicare experience preferred.
• Payor experience and/or experience with nationally recognized clinical criteria, including MCG

Education/Licensure:

• Graduate of an approved nursing program
• A current, unrestricted California RN  license

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