• Laguna Niguel, CA
  • Full Time - Days
  • Corporate
  • Req #: 10799
  • Posted: January 6, 2023
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HYBRID OPPORTUNITY! (1-2 in the office - Laguna Hills, California, 3 days remote)


**Candidates should live within 30 minutes from Laguna Hills, California**


Qualified candidate should possess:

  • Analyzing billing process for appropriate payment (reimbursement) 
  • Claims processing: coordination of disputed, rejected and delayed claims
  • Review returned, disputed and rejected claims from Government and 3rd party payers. 
  • Communicating with billers regarding coding processes preventing future denials
  • 1+ year of insurance/collection experience in a Healthcare environment
  • HMO's, PPO's, POS, and Medicaid


Here we Grow! Because the need to care for children in this age is growing and changing, we are looking for an intelligent, caring Reimbursement Specialist - Healthcare who will join a mission-driven group that is focused on the health of children and the well-being of the family from an operational perspective. Our healthcare practice has grown from its South Florida roots since 1955 across Texas, California, Arizona, New York and there is more to come. At Pediatric Associates, our employees receive competitive salary, a generous PTO program, competitive benefits including a 401K with a Company match of up to 3.5%. With over 65 years of providing LOVING CARE to our patients, we offer the stability and security of an established practice with the excitement of a growing healthcare organization.

Apply on line, email or call us directly, and learn why this is a rewarding career move for you! This is a wonderful time to join our Big Orange PA Family!

Benefits at a glance:

  • 3 Comprehensive Medical Plans
  • Part Time Medical Plan
  • Dental
  • Vision
  • Basic Life and Accidental Death and Dismemberment (AD&D) Company Paid
  • Long Term Disability (LTD) Company Paid
  • Short Term Disability (STD)
  • Voluntary Term Life Insurance (Employee/Spouse/Child)
  • 401K Retirement Plan
  • Voluntary Benefit Plans
  • Life Assistance Plan (EAP)
  • Tuition Reimbursement
  • Paid Time Off
  • Paid Holidays


PRIMARY FUNCTION:  Reimbursement Specialist is responsible for analyzing the billing process to determine appropriateness in payment (reimbursement). This position manages all components of claims processing including: 1) coordination of disputed, rejected, and delayed claims, and 2) to problem solve and review returned, disputed or rejected claims from Government and other third party Payers. Additionally, this position is responsible for communicating with billers regarding coding processes to prevent future denials.

REPORTS TO: Revenue Cycle Manager




  1. Processes correspondence related to assigned contracted and/or non-contracted insurance carriers including self-pay accounts.


  1. Researches denied and improperly processed claims by contacting assigned carriers to ensure proper processing of said claims. Call and check claim status, work A/R and insurance carrier reports, and insurance denials. Verifies insurance eligibility / PCP / patient benefits to reconcile denied claims.
  2. Identifies and corrects any claim processing errors due to data entry, verification, coding and/or posting. Add or update insurance carriers into practice management system. Review the Financial Class and the Insurance Group and verify that they are in the correct financial reporting groups.


  1. Resubmits improperly paid/denied claims to the carrier for proper payment in a timely manner.


  1. Monitor payer payment policies (bundling process) for each carrier to ensure guidelines are followed.


  1. Responsible for validating appeal opportunities, creating appeal letters, generating and submitting individual and/or batch appeals in a timely manner, tracking appeals and recoveries. Follow up on outstanding appeals, and work closely with the appropriate teams to validate contracts.


  1. Communicate and escalate denial trends, short payments, or payer policies to Management.


  1. Other various duties as assigned, including cross training in other functional areas.


*Non patient-facing




Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI in accordance with organizational policy, Federal, State, and local regulations.



Indoor Work

Operating Computer

Reach Outward

Manual Dexterity

Lift/Carry 20 lbs. or less

Push/Pull 12 lbs. or less



Other Physical Requirements


Sense of Sound

Sense of Touch


EDUCATION: High school diploma/GED or equivalent.




EXPERIENCE: Minimum of 1 year of insurance/collection experience in a medical environment preferred.


  • Knowledge of billing and collection policies and procedures, all types of insurance (HMO, PPO, POS, Medicaid etc.)
  • Skill in defining problems, diagnostics of common coding errors, and impact on claims processing, collection of data, interpreting billing information.
  • Must possess strong interpersonal skills; must be able to communicate effectively with co-workers, the Business Office Manager and must be able to work effectively as a team member within the Business Office.
  • Ability to multi-task in a face paced environment while meeting established production and quality goals/metrics.
  • Strong organizational skills, with ability to effectively prioritize work and daily basis and follow up on open items in a timely manner.


The expected hourly range for this position located in Laguna Niguel, California is $17.80 to $29.66. It is not typical for offers to be made at or near the top of the range. Pediatric Associates offers are based on several factors including but not limited to the candidate’s education, work experience, and certifications, all of which are dependent on the requirements of the specific role.  In addition to base salary, the Pediatrics Associates Family of Companies and it’s affiliates offers a comprehensive benefits package, potential incentive and recognition programs, and retirement planning (all benefits are subject to eligibility requirements based on position, and division).


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