Claims Specialist Quality Assurance I

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 Claims Quality Assurance (QA) Manager and Supervisor, the Claims Specialist Quality Assurance (CSQA) is responsible for ensuring the integrity of all data created and updated by the Claims Processing staff. The CSQA will utilize quality auditing tools, identify training needs, and define effective and efficient methods for accurate data entry and adjudication.

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
• 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 assess data reports and audit Claim Processor output to confirm payment accuracy and completeness of data entry.
2. In-house expert for claims adjudication (Coordination of Benefits, pricing, contract interpretation, coding, and resolution of claims issues.)
3. Ensure that all identified errors are corrected in an expedient manner.
4. Be an active participant in the Claims Department’s initiatives and participate in the Claims Coaching process, MDI activities, etc.
5. Assist with the processing of claims when necessary to address claims backlogs. Process approved Stop Loss reimbursements.
6. Any other duties as required, to ensure the success of the organization.
7. Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.

Education & Requirements 

• Two (2) years of experience in examining and processing institutional and professional claims
• Medicare/Medi-Cal experience preferred
• Experience in a managed care environment helpful
• High school diploma or GED required

Key Qualifications

• ICD-9/ ICD-10 and CPT coding and general practices of claims processing. Familiarity of Webstrat, Optum and CMS pricing
• Excellent communication and interpersonal skills, strong organizational skills
• Microcomputer skills, proficiency in Windows applications preferred
• Professional demeanor

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

Telecommute (All IEHP positions approved for telecommute 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)