Claims Specialist I - Provider Claims

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!

Under the direction of the Provider Claims Resolution & Recovery Supervisor, the Claims Specialist I - Provider Claims is responsible for evaluating professional, high dollar and outpatient/inpatient institutional claims while determining coverage and payment levels. Responsible for evaluating and resolving provider disputes & appeals, issuing resolution letters, and processing adjustment requests timely and accurately in accordance with standard procedures that ensure compliance with regulatory guidelines. Additional responsibilities include payment adjustment projects and complex claims as assigned.

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.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary.
• Telecommute schedule.
• CalPERS retirement.
• State of the art fitness center on-site.
• Medical Insurance with Dental and Vision.
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development.
• Wellness programs that promote a healthy work-life balance.
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

1. Review and process provider dispute resolutions according to state and federal designated timeframes.
2. Research reported issues; adjust claims and determine the root cause of the dispute.
3. Draft written responses to providers in a professional manner within required timelines.
4. Independently review and price complex edits related to all claim types to determine the appropriate handling for each including payment or denial.
5. Complete the required number of weekly reviews deemed appropriate for this position. 
6. Respond to provider inquiries regarding disputes that have been submitted.
7. Maintain, track, and prioritize assigned caseload through IEHP’s provider dispute database to ensure timely completion.
8. Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed.
9. Communicate with a variety of people, both verbally and in writing, to perform research, gather information related to the case that is under review.
10. Recommend opportunities for improvement identified through the trending and analysis of all incoming PDRs.
11. Coordinate with other departments as necessary to facilitate resolution of claim related issues.  Identify and report claim related billing issues to various departments for provider education.
12. Any other duties as required to ensure Health Plan operations are successful.
13. Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.

Education & Requirements

• Minimum of four (4) years of experience evaluating and processing institutional and professional medical claims
• Proficiency in the following areas: Medical claims system, ICD-10 and CPT coding, Reviewing medical authorizations, Provider contract rate interpretation, medical benefit coverage determination
• Prior experience handling provider disputes, appeals and claim adjustments
  • Experience preferably in and HMO or Managed Care setting
  • Medicare and/or Medi-Cal experience preferred
  • Experience in a managed care or government payer environment helpful
• High School Diploma or GED required

Key Qualifications

• A thorough understanding of claims industry and customer service standards
• Knowledge of ICD-9, ICD10, CPT, HCPC coding and general practices of claims processing
• Strong analytical and problem-solving skills
• Microsoft Office, Advanced Microsoft Excel
• Written communication skills
• Ability to analyze data and interpret regulatory requirements
• Excellent communication and interpersonal skills, strong organizational skills, and skilled in data entry required
• Typing a minimum of 45 wpm
• Excellent oral and written communication skills
• Ability to build successful relationships across the organization
• Professional demeanor
• Telephone courtesy and high degree of patience

Start your journey towards a thriving future with IEHP and apply TODAY!

Telecommute (All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership).