IEHP

Claims Specialist I – Provider Claims

IEHP

full-time

Posted on:

Location Type: Hybrid

Location: Inland Empire • California • United States

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Salary

💰 $26 - $33 per hour

About the role

  • Review and process provider dispute resolutions according to state and federal designated timeframes.
  • Research reported issues; adjust claims and determine the root cause of the dispute.
  • Draft written responses to providers in a professional manner within required timelines.
  • Independently review and price complex edits related to all claim types to determine the appropriate handling for each including payment or denial.
  • Complete the required number of weekly reviews deemed appropriate for this position.
  • Respond to provider inquiries regarding disputes that have been submitted.
  • Maintain, track, and prioritize assigned caseload through IEHP’s provider dispute database to ensure timely completion.
  • Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed.
  • Communicate with a variety of people, both verbally and in writing, to perform research, gather information related to the case that is under review.
  • Recommend opportunities for improvement identified through the trending and analysis of all incoming PDRs.
  • Coordinate with other departments as necessary to facilitate resolution of claim related issues.
  • Identify and report claim related billing issues to various departments for provider education.
  • Any other duties as required to ensure Health Plan operations are successful.
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.

Requirements

  • Minimum of four (4) years of experience evaluating and processing institutional and professional medical claims.
  • Proficiency in the following areas: Medical claims system, ICD-10 and CPT coding, reviewing medical authorizations, Provider contract rate interpretation, medical benefit coverage determination.
  • Prior experience handling provider disputes, appeals and claim adjustments.
  • Experience preferably in an HMO or Managed Care setting.
  • Medicare and/or Medi-Cal experience preferred.
  • Experience in a managed care or government payer environment preferred.
  • High school diploma or GED required.
  • Must have a valid California Driver's license.
  • A thorough understanding of claims industry and customer service standards.
  • Knowledge of ICD-9, ICD10, CPT, HCPC coding and general practices of claims processing.
  • Strong analytical and problem-solving skills.
  • Microsoft Office, Advanced Microsoft Excel.
  • Written communication skills.
  • Ability to analyze data and interpret regulatory requirements.
  • Excellent communication and interpersonal skills, strong organizational skills, and skilled in data entry required.
  • Typing a minimum of 45 wpm.
  • Excellent oral and written communication skills.
  • Ability to build successful relationships across the organization.
  • Professional demeanor.
  • Telephone courtesy and high degree of patience.
Benefits
  • Competitive salary.
  • Telecommute schedule.
  • CalPERS retirement.
  • State of the art fitness center on-site.
  • Medical Insurance with Dental and Vision.
  • Life, short-term, and long-term disability options
  • Career advancement opportunities and professional development.
  • Wellness programs that promote a healthy work-life balance.
  • Flexible Spending Account – Health Care/Childcare.
  • CalPERS retirement 457(b) option with a contribution match.
  • Paid life insurance for employees.
  • Pet care insurance.
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
ICD-10 codingCPT codingmedical claims processingprovider dispute resolutionclaims adjustmentmedical benefit coverage determinationdata analysisregulatory interpretationdata entrytyping
Soft Skills
analytical skillsproblem-solving skillswritten communication skillsorganizational skillsinterpersonal skillsprofessional demeanortelephone courtesypatiencerelationship buildingcommunication skills
Certifications
high school diplomaGEDCalifornia Driver's license