Location: Remote (Candidates must reside in Southern California near Rancho Cucamonga, CA)
Description:
The Claims Specialist II – Provider Claims is responsible for providing technical support to appeals and support staff while ensuring that appeals and call center activities are handled consistently and accurately.
This role involves managing escalated claim-related inquiries, assisting with cross-training, performing complex claim adjustments, and processing provider disputes in accordance with regulatory requirements.
The Claims Specialist II will also support root cause analysis of claim issues, collaborate with internal departments to implement preventive solutions, identify training opportunities, and recommend process improvements to enhance operational efficiency.
What You Will Do:
- Review and process provider dispute resolutions in accordance with state and federal regulatory timeframes.
- Review and assist with applying identified refunds submitted by designated internal teams.
- Research reported claim issues, make necessary adjustments, and determine the root cause of disputes.
- Prepare professional written responses to providers within established deadlines.
- Independently review and price complex claim edits across all claim types to determine appropriate payment or denial decisions.
- Complete required weekly claim reviews and meet established productivity expectations.
- Respond to provider inquiries regarding submitted disputes and claim resolutions.
- Maintain, track, and prioritize assigned caseloads using the provider dispute database to ensure timely resolution.
- Maintain current knowledge of claims processing procedures, regulatory requirements, and relevant reference materials.
- Communicate with internal teams and external stakeholders to gather information and facilitate dispute resolution.
- Identify trends in provider dispute resolutions (PDRs) and recommend opportunities for process improvement.
- Collaborate with other departments to resolve claim-related issues and support provider education regarding billing concerns.
- Assist with cross-training, identify training needs, and recommend Lean workflow improvements.
- Protect confidential patient information and ensure compliance with HIPAA regulations and organizational privacy policies.
- Perform additional duties as needed to support successful health plan operations.
You Will Be Successful If:
- You can independently research, analyze, and resolve complex provider claims and disputes accurately and efficiently.
- You consistently meet regulatory deadlines, productivity goals, and quality standards.
- You demonstrate strong analytical and problem-solving skills when identifying root causes of claims processing issues.
- You effectively communicate claim determinations and dispute resolutions to providers and internal stakeholders.
- You maintain organized caseloads, prioritize competing responsibilities, and consistently follow through on assigned tasks.
- You collaborate effectively with cross-functional teams to resolve claim-related issues and improve operational processes.
- You identify opportunities to improve claims workflows, reduce recurring disputes, and support provider satisfaction.
- You maintain a professional demeanor, demonstrate patience, and provide excellent customer service.
- You handle sensitive information with discretion and maintain compliance with HIPAA requirements.
What You Will Bring:
- High school diploma or GED.
- Minimum of four (4) years of experience in a managed care environment involving claims processing, appeals, adjustments, and customer service.
- Thorough understanding of medical claims processing procedures and customer service standards.
- Knowledge of claims appeals processes, provider contracts, claims system functionality, and medical billing practices.
- Strong analytical, research, and problem-solving skills.
- Proficiency in Microsoft Office applications, including advanced Microsoft Excel.
- Excellent written and verbal communication skills.
- Strong interpersonal and customer service skills.
- Strong data entry skills with a minimum typing speed of 45 words per minute.
- Ability to establish and maintain effective working relationships across departments.
- Strong organizational skills, attention to detail, and the ability to manage multiple priorities.
- Professional demeanor and a high degree of patience.
Preferred Qualifications:
- Experience working within a Health Maintenance Organization (HMO) or managed care setting.
- Experience with Medi-Cal and/or Medicare claims processing.
- Previous experience in a lead role.
- Proficiency with Windows-based applications.
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That’s Impresiv!
