Claims Specialist I - Provider Claims

Inland Empire Health Plans; California; On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Competitive salary

On-site fitness center

Medical, Dental, Vision

Life insurance and disability

Career advancement

Wellness programs

Flexible Spending Account

CalPERS retirement

457(b) option with match

Pet care insurance

Job summary

Inland Empire Health Plans is seeking a Claims Specialist I - Provider Claims to evaluate and process professional and institutional medical claims under the supervision of the Provider Claims Resolution & Recovery Supervisor. The role emphasizes determining coverage and payment levels while handling provider disputes and appeals with timely resolution letters.

Ideal candidates bring four years of experience in claims evaluation, proficiency in ICD-10 and CPT coding, and strong analytical,

Qualifications

• Four years of experience evaluating and processing institutional and professional medical claims.
• Proficiency in medical claims system, ICD-10 and CPT coding.
• Experience with provider disputes, appeals and claim adjustments.
• Experience in HMO/Managed Care setting preferred.
• Medicare and/or Medi-Cal experience preferred.

Responsibilities

• Evaluate professional, high-dollar and outpatient/inpatient institutional claims and determine coverage and payment levels.
• Resolve provider disputes and appeals; issue resolution letters.
• Process adjustment requests timely and accurately per standard procedures.
• Participate in payment adjustment projects and complex claims as assigned.

Skills

Claims processing

ICD-10 coding

CPT coding

Data analysis

Excel

Regulatory compliance

Communication

Education

High School Diploma

Tools

Microsoft Office

Excel

Job description

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to anauthentic experience!

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.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary
• 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

Education & 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

Key Qualifications

• 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