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Providence Health & Services Compliance Request Specialist - Mission Hills *FT Days* in Mission Hills, California


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Providence is calling a Compliance Request Specialist (Full-Time/Day Shift) to Providence Medical Institute in Mission Hills , CA.

Please upload a current resume reflecting all relevant experience.

We are seeking a Compliance Request Specialist who will perform responsibilities that demonstrate competency and knowledge in HMO/EPO/PPO UM Management. Has knowledge of Medicare, Medi-Cal, benefit coverages, Health Plan Appeals and Grievances; peer to peer process; medical criteria; criteria hierarchy, member reading grade levels. Understands HMO Referral Turn Around Time (TAT) guidelines; Federal, State and Health Plan regulations for extension, carve out, denial and approval letters; Health Plan audit requirements; dialysis requirements; Serves as a liaison between patients, hospitals, health plans, case managers, Request Specialists and Medical Foundations and Medical Groups. Responsible for verification of all needed information to issue all compliance notices; which include extension, carve out, denial, and alternative approvals for medical groups and lines of businesses.

In this position you will:

  • Perform job functions timely and efficiently

  • Deliver upon the service expectations of both our patients and fellow staff members by listening to their needs; engaging in positive interactions; and following through on promises made in a thoughtful, efficient, timely and courteous manner so that their total outcome is better than expected

  • Work in a safe manner, adhering to general safety precautions and standards

  • Report any unsafe conditions to their supervisor and/or the safety hotline

  • Verify eligibility, benefits, and researches medical criteria for HMO assigned patients and updates the member’s records as necessary

  • Obtain Pre-cert for requests for inpatient services for Cigna members

  • Communicate and faxes information to Health Plans regarding investigational/experimental requests

  • Participate in health plan audits on site

  • Participate in health plan and CMS live file review

  • Prepare files for extension, carve out, denial and approval letters for health plan audits

  • Communicate with providers for additional information when appropriate

  • Monitor extension, carve out and denial queue in the referral system (GE/IDX and Cerecons) throughout the day

  • Be responsible for completion of all regulatory oral and written communication letters for denials, carve out and extension letter timely and accurately using correct templates for members and providers

  • Be responsible for reviewing denial letter language for accuracy and appropriate member readability level

  • Ensure that all documentation from Case Manager and Physician Reviewer is complete prior to issuing extension, carve out and/or denial letter. (i.e.: criteria; physician review form, case manager notes, decision date/time; alternative options if applicable, etc.)

  • Notify members and providers of routine/expedited/urgent determinations by phone, mail and fax per regulatory guidelines

  • Scan completed letters to the electronic medical record

  • Serve as liaison between patients, providers, health plans and the organization regarding extension, carve out and denial related information

  • Assist providers requesting peer to peer

  • Assist Quality Management in providing files for any member appeal and Health Plan overturns

  • Review and update referrals received (via EMR, fax, and calls) timely and accurately. Communicate timely with management team any barriers to meeting timelines

  • Research, reconcile, and update service authorizations on claims research requests. Enters extensions of dates, new authorizations, and/or confirms denials (per Case Manager’s review)

  • Assist case managers by gathering necessary information needed for review and assists with non-clinical outbound calls to patients

  • Forward any investigational or experimental requests and/or carved out services or appeals request to the member’s health plan for review

  • Be responsible for identifying denial issues and trends and reporting them to management for process improvement

  • Meet productivity and accuracy standards as established by management, inclusive of reporting daily production count

  • Be responsible for submission of management reporting as required based on business unit needs

  • Attend required/assigned meetings by the supervisor, manager and Director

  • The customer service standards of the organization are reflected in daily work habits

  • Patient and provider complaints are researched and responded to the same day if possible

  • Request from other departments are responded to in a timely and positive manner

  • Take initiative, when possible, and offers assistance to co-workers in overload situations

  • Physicians, plan representatives, members and co-workers are treated courteously

  • Demonstrate behaviors, which are consistent with the Code of Conduct and aligned with the organization’s mission, vision and shared values

  • Report promptly any suspected or potential violations to laws, regulations, procedures, policies and practices, and cooperates with investigations

  • Conduct all transactions in compliance with all company policies, procedures, standards and practices

  • Demonstrate knowledge of all applicable compliance and legal requirements of the job based on the scope of practice of the position

  • Respect the dignity, confidentiality and privacy of patients

  • Ensure that appearance and personal conduct are professional at all times

  • Adhere to policies and procedures on attendance and dress code

  • Work at maintaining a good rapport and a cooperative working relationship with staff and physician offices

  • Represent the organization in a positive and professional manner in the community

  • Maintain organizational, employee and patient confidentiality at all times


Required qualifications for this position includes:

  • One (1) year of experience in a clinic, hospital or related health care industry in a managed care environment, or equivalent in education or medical certification in medical field (i.e. nursing, medical billing and coding, or medical admin assisting)

  • Knowledge of HMO/EPO/PPO, Medicare, Medical insurance processing

  • Knowledge of ICD-10/CPT coding and medical terminology

  • Knowledge of HMO referral process requirements

  • Knowledge of HMO Referral Turn Around Time (TAT) guidelines

  • Familiar with medical criteria

  • Knowledge of Health Plan/Medical Group appeals and Grievances process

  • Knowledge of peer to peer process

  • Knowledge of Federal, State and Health Plan regulations and requirements for extension, carve out, denial and approval letters

  • Knowledge of Health Plan audit requirements

  • Familiar with dialysis requirements

  • Able to use 10-key calculator by touch or sight

  • Computer skills (MS Word, Outlook and Excel), type 45 wpm, and data entry experience

  • Able to multi-task and prioritize

  • Must possess excellent customer service, writing and communication skills, be organized and self-starter

About the location you will serve.

Providence Health & Services Southern California is further developing its physician integration strategy. Historically, the largest asset has been Providence Medical Institute, a medical foundation that provides administrative and other support services to affiliated medical groups. Providence Medical Institute is expected to grow significantly in the next several years, bringing with it facilities, staff and physician growth to support that objective.

We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: Full-time

Shift: Day

Job Category: Patient Services

Location: California-Mission Hills

Req ID: 312266