Claims Specialist II - Provider Claims Short-Term Assignment

IEHP; Rancho Cucamonga (CA); On-site; USD 78,598,000 - 102,179,000; Full time

Job summary

IEHP is seeking a Claims Specialist II – Provider Claims to support appeals, provider disputes, and call center tasks in a fast-paced managed care setting. You will perform complex claim adjustments, root cause analysis, and cross-train staff while ensuring accuracy and regulatory compliance with Medi-Cal/Medicare requirements.

The role emphasizes collaboration across units, Lean process improvements, and quality program goals such as HEDIS, CAHPS, and NCQA Accreditation.

Qualifications

• Four years of experience in a managed care environment in claims processing, appeals & adjustments, and customer service.
• High school degree or GED required.
• Medi-Cal/Medicare experience and lead role preferred.

Responsibilities

• Handle appeals and provider disputes and ensure call center tasks are accurate.
• Perform complex claim adjustment projects and root cause analysis.
• Cross-train staff and identify Lean improvements to unit workflows.
• Interface with other business units to establish preventive solutions.

Skills

Claims processing

Analytical skills

Communication skills

Microsoft Excel

Customer service

Typing 45 wpm

Education

High school diploma or GED

Tools

Microsoft Office

Excel

Windows applications

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 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.

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

Pay Range

• $27.43 USD Hourly - $35.66 USD Hourly