Claims Specialist

The Judge Group; Rancho Cucamonga (CA); Hybrid; USD 45,000 - 48,000; Full time

Benefits offered by this job

Medical, dental and vision insurance

Hybrid work arrangement

Job summary

Inland Empire Health Plan (IEHP) is seeking experienced Claims Specialist II professionals to support its Provider Claims team. This hybrid role focuses on investigating, reviewing, adjusting, and resolving complex provider claims and disputes while ensuring compliance with state and federal regulations.

The ideal candidate will have strong managed care claims experience, excellent analytical and communication skills, and a solid understanding of provider appeals, claims adjudication, and

Qualifications

• 4+ years of medical claims processing, claims appeals and adjustments
• Customer service experience in a Managed Care environment
• Strong knowledge of provider dispute resolution, medical claims adjudication, and reimbursement methodologies
• Advanced proficiency with Microsoft Excel
• Excellent written and verbal communication, high attention to detail, and 45 WPM typing

Responsibilities

• Review and resolve provider disputes within regulatory timelines.
• Research claim discrepancies and perform necessary adjustments.
• Analyze and price complex medical claims for accurate payment or denial.
• Process provider appeals and disputes in compliance with healthcare regulations.
• Prepare detailed written responses regarding claim determinations and dispute outcomes.
• Serve as a point of contact for provider inquiries related to claims and appeals.
• Monitor claim trends and suggest process improvements to reduce disputes.
• Support cross‑functional teams with claims expertise.
• Manage assigned caseloads meeting productivity and quality standards.
• Collaborate with internal departments to resolve claims and reimbursement issues.
• Review provider refund requests and support resolution activities.
• Identify opportunities for workflow optimization and efficiency improvements.
• Ensure HIPAA compliance and protection of confidential information.
• Participate in quality assurance and continuous improvement initiatives.

Skills

Excel

Analytical skills

Communication

Typing speed

Tools

Claims processing systems

Job description

Claims Specialist II - Provider Claims

Client: Inland Empire Health Plan (IEHP)

Location: Hybrid

Duration: Short-Term Contract Assignment

Openings: 4

Pay Rate: $33/hr - $35/hr

About the Role

Inland Empire Health Plan (IEHP) is seeking experienced Claims Specialist II professionals to support its Provider Claims team. This role focuses on investigating, reviewing, adjusting, and resolving complex provider claims and disputes while ensuring compliance with state and federal regulations. The ideal candidate will possess strong managed care claims experience, excellent analytical skills, and a thorough understanding of provider appeals, claims adjudication, and reimbursement methodologies.

What You'll Do

• Review and resolve provider disputes within established regulatory timelines.
• Research claim discrepancies, identify root causes, and perform necessary claim adjustments.
• Analyze and price complex medical claims to ensure accurate payment or denial determinations.
• Process provider appeals and disputes while maintaining compliance with healthcare regulations.
• Prepare detailed written responses regarding claim determinations and dispute outcomes.
• Serve as a point of contact for provider inquiries related to claims and appeals.
• Monitor claim trends and recommend process improvements to reduce future disputes.
• Support cross-functional teams by providing technical guidance and claims expertise.
• Manage assigned caseloads while meeting productivity, accuracy, and quality standards.
• Collaborate with internal departments to resolve claims, billing, and reimbursement issues.
• Review provider refund requests and support resolution activities.
• Identify opportunities for workflow optimization and operational efficiency improvements.
• Ensure HIPAA compliance and protect confidential member and provider information.
• Participate in quality assurance initiatives and continuous improvement efforts.

Minimum Qualifications

• High school diploma or GED required.
• 4+ years of experience in:
  • Medical claims processing
  • Claims appeals and adjustments
  • Customer service within a Managed Care, HMO, or health plan environment
• Strong knowledge of:
  • Provider dispute resolution (PDR)
  • Medical claims adjudication processes
  • Provider contracts and reimbursement methodologies
  • Claims processing systems
• Advanced proficiency with Microsoft Excel.
• Strong analytical, problem-solving, and critical-thinking skills.
• Excellent written and verbal communication abilities.
• High attention to detail with accurate data entry skills.
• Typing speed of at least 45 words per minute.
• Ability to manage multiple priorities and meet deadlines in a fast-paced environment.

Preferred Qualifications

• Experience with Medi-Cal claims processing.
• Experience with Medicare claims processing.
• Previous senior-level or lead claims experience.
• Expertise in handling complex provider appeals and dispute resolutions.
• Knowledge of Lean methodologies and process improvement practices.

Preferred Skills

• Provider Claims Processing
• Claims Appeals & Adjustments
• Provider Dispute Resolution (PDR)
• Root Cause Analysis
• Regulatory Compliance
• Customer Service
• Data Analysis & Reporting
• Process Improvement
• Professional Written Communication
• Time Management
• Cross-Functional Collaboration

Medical, dental, and vision insurance are available to qualified candidates who meet eligibility requirements

Medical, dental, and vision insurance are available to qualified candidates who meet eligibility requirements.