Claims Specialist I – Provider Claims
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Job Description
Claims Specialist evaluating and resolving provider medical claims for Inland Empire Health Plan. Determining coverage, payments, disputes, appeals, and adjustments.
Responsibilities:
- Evaluate professional, high dollar, and outpatient/inpatient institutional claims
- Determine coverage and payment levels
- Evaluate and resolve provider disputes and appeals
- Issue resolution letters
- Process adjustment requests timely and accurately in accordance with standard procedures and regulatory guidelines
- Participate in payment adjustment projects
- Handle complex claims as assigned
- Incorporate IEHP’s Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation
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 and HMO or Managed Care setting
- Medicare and/or Medi-Cal experience preferred
- Experience in a managed care or government payer environment helpful
- High School Diploma or GED required
- 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:
- 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
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