Claims Specialist I - Provider Claims

Job Summary
We are seeking a detail-oriented and knowledgeable Claims Specialist I to join our team. Under the direction of the Provider Claims Resolution & Recovery Supervisor, the Claims Specialist I - Provider Claims is responsible for evaluating professional, high dollar and outpatient/inpatient institutional claims while determining coverage and payment levels. Responsible for evaluating and resolving provider disputes & appeals, issuing resolution letters, and processing adjustment requests timely and accurately in accordance with standard procedures that ensure compliance with regulatory guidelines. Additional responsibilities include payment adjustment projects and complex claims as assigned.

Candidate will report to the Supervisor, Provider Claims Resolution and Recovery.

This position is fully remote. Candidates must reside in California. No out of state candidates will be reviewed.

Duties

• 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.

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 HMO or Managed Care setting. Medicare and/or Medi-Cal experience, as well as managed care or government payer environment is helpful.

Education Requirement

High School Diploma or GED required.

Skills

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. Billing experience will not be considered as actual claims processing or adjudicating experience.

Job Type: Full-time

Pay: $53,872.00 - $68,681.60 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• On-site gym
• Paid time off
• Retirement plan
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday
• No weekends

Experience:

• Medicare and Medi-Cal Claims processing: 4 years (Required)

Work Location: Remote

Salary : $53,872 - $68,682