Four years of experience in a managed care environment in claims processing, appeals, adjustments, and customer service (preferably in an HMO/Managed Care setting).
Thorough understanding of medical claim processing and customer service standards; Medi-Cal/Medicare experience and prior lead role preferred.
High school diploma or GED; valid California driver's license.
Strong analytical and problem-solving skills, proficiency in Microsoft Office (Advanced Excel), excellent verbal and written communication, and ability to type 45 wpm.
Requirements:
Review and process provider dispute resolutions according to state and federal designated timeframes.
Review and assist with applying identified refunds submitted by the CART team.
Research reported issues; adjust claims and determine the root cause of the dispute.
Draft written responses to providers in a professional manner within required timelines.
Job description
Title: Temporary Claims Specialist II - Provider Claims Assignment Length: Six Months
WORK LOCATION:10801 6th St STE 120, Rancho Cucamonga, CA 91730
Key Responsibilities:
Review and process provider dispute resolutions according to state and federal designated timeframes.
Review and assist with applying identified refunds submitted by the CART team.
Research reported issues; adjust claims and determine the root cause of the dispute.
Draft written responses to providers in a professional manner within required timelines.
Independently review and price complex edits related to all claim types to determine the appropriate handling for each including payment or denial.
Complete the required number of weekly reviews deemed appropriate for this position.
Respond to provider inquiries regarding disputes that have been submitted.
Maintain, track, and prioritize assigned caseload through IEHP’s provider dispute database to ensure timely completion.
Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed.
Communicate with a variety of people, both verbally and in writing, to perform research, gather information related to the case that is under review.
Recommend opportunities for improvement identified through the trending and analysis of all incoming PDRs.
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
Any other duties as required to ensure Health Plan operations are successful.
Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.
Qualifications
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 diploma or GED required
Key Qualifications
Must have a valid California Driver's license
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
