Providence St. Joseph Health

Job Information

St. Joseph Health / Covenant Health Lead Claims Representative in Anaheim, California

We are looking for a Lead Claims Representative for the Claims Department at Heritage Healthcare.

Location Anaheim, CA

Work Schedule: Full time - 80 Biweekly Hours

Shift: 8-hour, Days

Apply Today! Applicants that meet qualifications will receive a text with some additional questions from our Modern Hire system.

Job Summary:

Working under the direction of the Revenue Recovery Director, this position has sole responsibility for 48 hr. claims adjudication and health plan capitation deduction reconciliation and disputes. In addition, this position will assist with interviewing/hiring, orientation, and training of new employees.

Essential Functions:

  • Sole responsibility for all health plans/ all networks 48 hr. claims adjudication to maintain minimal capitation deductions from the health plans. In addition, this position will assist with orientation/training new employees as well as participate in the hiring process.

  • Maintains a database system for tracking the monthly health plan cap deducts, entering data into database and then following up with the discrepancies directly with the plans.

  • Audits the health plan quarterly claims data to identify duplicate payments to providers and then issuing refund requests to providers or appealing for “credit” from the health plan.

  • Establish and maintain open communication with contact persons at each health plan to facilitate objective actions regarding cap deducts.

  • Maintains knowledge for claims processing guidelines, provider contracts, DOFRs, and compliance regulations when processing claims.

  • Understands each health plan’s contractual obligations with respect to notification of potential cap deducts.

  • Solely responsible to resolve HP disputes, coordinating with Regional Contracting and Network Provider Relations.

  • Tracks and monitors database for outstanding cap deduct issues with health plans and providers.

  • Assists TPL with respect to identifying TPL cases when reviewing health plan 48 hr. claims and cap deduct data.

  • Assists TPL with respect to researching/processing claims for timely closing of a TPL case.

  • Orients, trains and mentors current and new employees as needed.


  • Basic computer skills including MS Word, Excel, Access and emailing system.

  • 10 key by touch.

  • Ability to work under pressure by prioritizing work activities and re-negotiating deadlines.

  • Strong analytical and problem solving skills.

  • Excellent verbal, written and interpersonal communications skills to communicate effectively with individuals at all levels of the organization.

  • Excellent organizational and prioritization skills.

  • Critical thinking and problem resolution.

  • Knowledge of HIPAA and AB1455.

  • Ability to work independently, but also as a team player, supporting and promoting intra and inter-departmental teamwork.

  • Professional and mature demeanor, maintaining a positive attitude with changing conditions.

  • Ability to make sole judgment calls with confidence.

  • Ability to lead and delegate tasks appropriately.

Minimum Position Requirements:

Education: H.S. Diploma or GED.


  • 4 years experience in medical/institutional claims processing within a medical group/IPA setting

  • Experience with computerized claims processing/transactions system and medical coding (CPT, ICD10, and HCPCs).

Preferred Position Qualifications:

Education: Associate's Degree

Experience: IDX experience.

Mission Heritage Medical Group is one of California's most respected medical groups. With over 3,000 employees and 75 locations throughout California, including, Northern California, Orange County, High Desert and Los Angeles County, Mission Heritage Medical Group has been continually recognized as a leader in quality, customer service and information technology. This kind of success is the result of team work, a commitment to excellence and a strong adherence to the organization's mission, vision and values. Mission Heritage Medical Group provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Mission Heritage Medical Group complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Company: Heritage Healthcare

Category: Billing/ Insurance

Req ID: R332018