Claims Specialist I - Provider Claims

Inland Empire Health Plan

8d•$26 - $33•Remote

About The 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 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.

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
High school diploma or GED required
Must have a valid California Driver's license
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

Nice To Haves

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 preferred

Responsibilities

Review and process provider dispute resolutions according to state and federal designated timeframes.
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.