Provider Claims Specialist II - Appeals & Analytics

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

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.