Claims Specialist II - Provider Claims Short-Term Assignment

Inland Empire Health Plans; California (MO); On-site; USD 60,000 - 75,000; Full time

Job summary

Inland Empire Health Plans is seeking a Claims Specialist II – Provider Claims to support appeals, complex claim adjustments, and provider disputes. The role emphasizes accurate processing of provider claims and handling escalated inquiries for the call center.

You will perform root cause analyses, interface with other units to implement preventive solutions, and identify Lean improvements across workflows while upholding IEHP's commitment to quality and regulatory compliance.

Qualifications

• Four years of experience in claims processing including appeals and adjustments in a managed care setting.
• Knowledge of Med-Cal/Medicare and customer service standards.

Responsibilities

• Handle appeals and provider disputes; assist with complex claim adjustments.
• Respond to escalated claim-related inquiries from providers and staff.
• Perform root cause analyses for identified claim issues and interface with other units to implement preventive solutions.
• Identify training needs and Lean improvements to workflows within the unit.

Skills

Claim processing

Customer service

Analytical skills

Data entry

Typing 45 wpm

Lead experience

Medi-Cal/Medicare knowledge

Education

High School Diploma or GED

Tools

Microsoft Office

Advanced Microsoft Excel

Windows

Job description

This is a short-term assignment.

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!

The Claims Specialist II – Provider Claims is responsible for fulfilling the technical support needs of appeals and support staff, while ensuring that appeals and call center tasks are conducted consistently and accurately. Additional responsibilities include handling escalated claim-related telephone inquiries, assisting with cross-training as needed, performing complex claim adjustment projects, and processing Provider Disputes in accordance with regulatory requirements.

Additionally, the Claims Specialist II – Provider Claims will help perform root cause analysis for identified claim issues and interface with other business units to establish preventive solutions. The Claims Specialist II – Provider Claims will help identify training needs and identify Lean improvements to all unit workflows.

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.

Education & Requirements

• Four (4) years of experience in a managed care environment in the area of claims processing; appeals & adjustments, and customer service, preferably in an HMO or Managed Care setting
• A thorough understanding of medical claim processing and customer service standards.
  • Medi-Cal/Medicare experience and prior experience in a lead role preferred
• High school degree or GED required

Key Qualifications

• Understanding of claim appeal process, provider contracts, claim system functionality and medical claim processing practices
• Strong analytical and problem-solving skills
• Microsoft Office, Advanced Microsoft Excel
• Microcomputer skills, proficiency in Windows applications preferred
• Excellent oral and written communication skills
• Excellent communication and interpersonal skills
• Customer service skills and skilled in data entry required
• Typing a minimum of 45 wpm
• Ability to build successful relationships across the organization
• Professional demeanor and strong organization skills. High degree of patience