Job details
Salary $48,110 - $59,426 a year
Full job description
Position summary/position
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 levelsResponsible 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 guidelinesAdditional responsibilities include payment adjustment projects and complex claims as assignedMajor functions (duties and responsibilities)
1Review and process provider dispute resolutions according to state and federal designated timeframes.
2Research reported issues; adjust claims and determine the root cause of the dispute.
3Draft written responses to providers in a professional manner within required timelines.
4Independently review and price complex edits related to all claim types to determine the appropriate handling for each including payment or denial.
5Complete the required number of weekly reviews deemed appropriate for this position.
6Respond to provider inquiries regarding disputes that have been submitted.
7Maintain, track, and prioritize assigned caseload through iehp’s provider dispute database to ensure timely completion.
8Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed.
9Communicate with a variety of people, both verbally and in writing, to perform research, gather information related to the case that is under review.
10Recommend opportunities for improvement identified through the trending and analysis of all incoming pdrs.
11Coordinate with other departments as necessary to facilitate resolution of claim related issuesIdentify and report claim related billing issues to various departments for provider educationMajor functions (duties and responsibilities) cont supervisory responsibilities leading: self experience qualifications
Minimum of four (4) years of experience evaluating and processing institutional and professional medical claimsProficiency in the following areas: medical claims system, icd-10 and cpt coding, reviewing medical authorizations, provider contract rate interpretation, medical benefit coverage determinationPrior experience handling provider disputes, appeals and claim adjustmentsPreferred experience
Experience preferably in and hmo or managed care settingMedicare and/or medi-cal experience preferredExperience in a managed care or government payer environment helpfulEducation qualifications
High school diploma or ged requiredPreferred education professional certification professional licenses drivers license required yes, must have a valid california driver`s licenseKnowledge requirement
A thorough understanding of claims industry and customer service standardsKnowledge of icd-9, icd10, cpt, hcpc coding and general practices of claims processingSkills requirement
Strong analytical and problem-solving skillsMicrosoft office, advanced microsoft excelWritten communication skillsAbility to analyze data and interpret regulatory requirementsExcellent communication and interpersonal skills, strong organizational skills, and skilled in data entry requiredTyping a minimum of 45 wpmExcellent oral and written communication skillsAbilities requirement
Ability to build successful relationships across the organizationProfessional demeanorTelephone courtesy and high degree of patienceCommitment to team culture
The iehp team environment requires a team member to participate in the iehp team cultureA team member demonstrates support of the culture by developing professional and effective working relationships that include elements of respect and cooperation with team members, members and associates outside of our organizationWorking conditions
Sedentary work in an office environmentWork model location physical requirements keyboarding: traditional - frequently keyboarding: other - frequently use of computer mouse - frequently hearing: one-on-one - frequently hearing: in a group - frequently hearing: over the telephone/cell phone - frequently hearing: conference speakers/video calls/radio calls - frequently near visual acuity - frequently communicate: information/ideas verbally - frequently alternate sit/stand or walk at will - frequently turning/rotation of wrist or hand - frequently indoors - constantly lighting - constantly perform complex and varied tasks - frequently develop and maintain positive work relationships - constantly regular contacts: co-workers, supervisor - frequently decision-making - frequently lead/influence others - frequently work review - frequently rapid pace of work - frequently control of work pace - frequently problem solving - frequently memory - frequently understand and follow direction - frequently regular and reliable attendance - constantly
Starting salary: $48,110.40 - $59,425.60
Pay rate will commensurate with experience
Inland empire health plan (iehp) is the largest not-for-profit medi-cal and medicare health plan in the inland empireWe are also one of the largest employers in the regionWith a provider network of more than 6,000 and a team of more than 2,000 employees, iehp provides quality, accessible healthcare services to more than 1.2 million membersAnd our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplaceAs the healthcare landscape is transformed, we’re ready to make a difference today and in the years to comeJoin our team and make a difference with us! iehp offers a competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.
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Posted 10 days ago
