Lead Claims Specialist - Claims Processing

Providence; Mission Hills (CA); On-site; USD 120,000 - 150,000; Full time

Job summary

Join Providence Medical Foundation to contribute to patient-focused care, culture, and continuous improvement in claims operations, policy implementation, and regulatory compliance across the organization.

Qualifications

• 5 years professional and facility claims processing experience.

Responsibilities

• Manage the claims internal audit functions, including audit processes for adjudicated claims and encounters.
• Monitor check run processes for accuracy.
• Develop policies and procedures for periodic claims audits and ensure compliance with affiliated health plans, client groups, and administrative contractual agreements.
• Design, plan, direct and implement claims training programs for the organization, including adaptations to changes in policies, procedures and technologies.
• Must be familiar with applicable State and Federal claim payment and denial timeliness legislation.
• Must be familiar with Timeliness Compliance pursuant to State and Federal rules and regulations.
• Must be well versed regarding the Provider Dispute Resolution tracking mechanism (AB1455).

Skills

Claims processing

Auditing

Policy development

Training programs

Regulatory compliance

Job description

Manage the claims internal audit functions, which includes audit process for adjudicated claims and encounters. Monitor check run process for accuracy. Develop policies and procedures for periodic claims audits and ensure compliance with affiliated health plans, client groups, and administrative contractual agreements. Designs, plans, directs and implements claims training programs for the organization, to include adaptations to changes in policies, procedures and technologies. Must be familiar with applicable State and Federal claim payment and denial timeliness legislation. Must be familiar with Timeliness Compliance pursuant to State and Federal rules and regulations. Must be well versed regarding the Provider Dispute Resolution tracking mechanism (AB1455).

Providence caregivers are not simply valued – they’re invaluable. Join our team at Providence Medical Foundation and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.

Required Qualifications:

• 5 years professional and facility claims processing experience

Why Join Providence?

Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.