Claims Specialist - Covered California

Inland Empire Health Plan

12d•$26 - $33•Remote

About The Position

Under the direction of the Covered California Claims (CCA) Manager, the CCA Claims Specialist is responsible for analyzing, managing, and investigating complex and high-dollar healthcare claims that require in-depth research to determine accuracy and mitigate payment errors. The Claims Specialist is also responsible for adjusting first-pass and post-pay claims that result in overpayment or underpayment due to claim processing system issues, contract amendments, processing errors, or other issues. This position collaborates with internal stakeholders, assists with claim audits (internal and regulatory) and utilizes strong analytical skills and independent judgement skills to make effective and accurate decisions. This position will also be responsible for responding to inquiries from the Provider Payment Resolution team on claims that may have been paid incorrectly. 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

Three (3) years of experience in examining and processing complex and high-dollar institutional and professional claims
High school diploma or GED required
ICD-9/ ICD-10 and CPT coding and general practices of claims processing
CMS/DMHC and Affordable Care Act regulations and guidelines
Excellent communication and interpersonal skills
Excellent analytical, critical thinking, customer service, and organizational skills
Ability to think critically with the capacity to work independently
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

Nice To Haves

Experience in a managed care environment helpful. Commercial, Exchange, and Medicare preferred
Associate’s degree from an accredited institution preferred
Commercial line of business specifically Covered California/Exchange

Responsibilities

Work effectively with other departments (i.e., Special Investigation Unit, Provider Payment Resolution team, and other departments/stakeholders) to investigate and identify fraud, respond to escalated provider inquiries timely, and support the claims process.
Investigate and process complex and high-dollar claims determining accuracy and making timely decisions.
Advise leadership and internal business units (as applicable) of findings and outcomes on identified claim issues.
Research and analyze medical claims adjustment requests along with related documentation to determine payment accuracy and adjust/adjudicate as needed in the Health Rules Processing system and other platforms.
Research claims that may have been paid incorrectly and communicate findings for adjustment. Adjust claims based on findings (i.e., correct coding, rates of reimbursement, authorizations, contracted amounts, etc.) ensuring that all relevant information is considered.
Assist with internal and regulatory claim audits, reviewing claim accuracy.
Identify trends and recommend improvements to IEHP’s claim processing system.
Analyze and investigate insurance claims to discover or prevent fraud.
Be an active participant in the Claims Department’s initiatives and participate in Claims Huddles, etc.
Remain current with all claim processing changes/updates (i.e. internal processes, regulatory guidelines).
Perform any other duties as required to ensure Health Plan operations and department business needs are successful.