Claims Specialist II - Provider Claims
About The Position
The Claims Specialist II – Provider Claims provides technical support to appeals and support staff and helps ensure appeals and call center activities are handled consistently and accurately. The role manages escalated claim-related inquiries, performs complex claim adjustments, processes provider disputes in accordance with regulatory requirements, and supports root cause analysis and preventive solutions. It also contributes to cross-training, identification of training needs, and process improvements to enhance operational efficiency. The position reviews and resolves provider disputes, researches reported claim issues, makes claim adjustments, and independently reviews and prices complex claim edits across claim types to determine payment or denial decisions. The specialist communicates resolutions to providers and internal stakeholders, maintains an organized caseload, and works with other departments to resolve claim issues and support provider education. The role requires protecting confidential patient information and complying with HIPAA and organizational privacy policies. This position is remote for candidates who reside in Southern California near Rancho Cucamonga, California.
Requirements
- High school diploma or GED.
- Minimum of four 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 and 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 ability to manage multiple priorities.
- Professional demeanor and a high degree of patience.
- Candidates must reside in Southern California near Rancho Cucamonga, California.
Nice To Haves
- 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.
Responsibilities
- 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 and recommend process improvements.
- 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 comply with HIPAA regulations and organizational privacy policies.
- Perform additional duties as needed to support successful health plan operations.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
