Claims Specialist I - Provider Claims

IEHP; Rancho Cucamonga (CA); Presencial; USD 36.000 - 45.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Competitive salary

On-site fitness center

Medical Insurance with Dental and Visa

Life and disability options

Career advancement opportunities

Wellness programs

Flexible Spending Account

CalPERS retirement

457(b) option

Paid life insurance

Pet care insurance

Descripción de la vacante

Join IEHP as a Claims Specialist I - Provider Claims, responsible for evaluating and processing institutional and professional medical claims under the direction of the Provider Claims Resolution & Recovery Supervisor. Your role includes resolving provider disputes, issuing resolution letters, and processing adjustment requests efficiently to comply with regulations.

We value your dedication to improving our Member's experience and offer numerous perks, including competitive salary, medical

Formación

• Minimum of four years of experience with institutional and professional medical claims.
• Proficient in medical claims systems and coding, including ICD-10 and CPT.
• Experience handling provider disputes, appeals, and claim adjustments.

Responsabilidades

• Evaluate and process institutional and professional medical claims.
• Resolve provider disputes and appeals, issue resolution letters.
• Ensure compliance with regulatory guidelines.

Conocimientos

Claims processing

ICD-10 coding

CPT coding

Analytical skills

Microsoft Office

Interpersonal skills

Data entry

Communication skills

Telephone courtesy

Educación

High School Diploma or GED

Herramientas

Microsoft Excel

Descripción del empleo

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 an authentic 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.

authentic 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.

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.

Perks

• 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

Pay Range

• $25.90 USD Hourly - $33.02 USD Hourly