Provider Claims & Appeals Specialist II

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

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.