Under the general direction of the Medical Director, the Claims Review Nurse is responsible for reviewing medical bills and documentation using good judgment to make decisions regarding appropriate billing practices and communicating decisions to all stakeholders both internal and external. Position is responsible for remaining informed on billing and payment legislation and complying with all regulations related to review and payment. Claims Review Nurse will at all times maintain strict confidentiality on behalf of RMG/HPN members, providers and other stakeholders. Responsibilities: Act as a medical and technical resource for the claims department and medical director. Provide technical review of claims and medical records including records submitted by providers and internal records provided in EZCap and other electronic databases. Review claims for medical necessity, coding and assure payment per the terms of the contract, member benefits and authorization. Follow all timelines both internal and external for claims payment. Prepare both internal and external documentation, assuring clarity in communication to all stakeholders. When necessary, meet with external and internal clients reviewing decisions and improving processes for better documentation and communication. Apply knowledge of medical bill analysis relating to state/federal regulations affecting medical billing practice. Apply knowledge as they relate to medical interpretation based on Regal Medical Group/Heritage Provider Network guidelines. Conduct an analytical review to identify any potential third party or Workers’ Compensation liability and inform management. Monitor and communicate with appropriate internal staff when identifying questionable billing practices or third party collection opportunities. Oversee the training and resource material as needed to reduce claim processing errors. May require travel to regional offices. All other duties as directed by management. The pay range for this position at commencement of employment is expected to be between for LVN's $37.50 - $40 per hour or for RN's $45 - $50 per hour ; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience. The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered. Details of participation in these benefit plans will be provided if an employee receives an offer of employment. If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors. 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). Behavioral Health Services. Savings and Retirement: 401k Retirement Savings Plan. Income Protection Insurance. Other Benefits: Vacation Time. Company celebrations. Employee Assistance Program. Employee Referral Bonus. Tuition Reimbursement. License Renewal CEU Cost Reimbursement Program. 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. Requirements: Must have an active nursing license (RN) in the state of California with no restrictions and a minimum of 1 year of patient care experience in a hospital setting. Must be able to perform with minimum supervision. Full working knowledge of medical group/managed care environment including capitation, TPL, COB, PPO, and POS. Knowledge of DRG Grouper, 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. Excellent written and verbal communication skills. Strong organizational and problem solving skills. 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