Claims Specialist I – Provider Claims

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🔥 1 minute ago

🏄 California – Remote

🏄 California – Remote

💵 $25 - $33 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Claims Specialist

👻 Ghost score 2%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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IEHP

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1995

🛡️ Insurance

💼 Consulting

📦 Logistics

💰 Grant on 2021-02

Insurance • Consulting • Logistics

IEHP is a health plan dedicated to serving low-income individuals and families in Riverside and San Bernardino counties. They offer a variety of programs including Medi-Cal, DualChoice, and Covered California, providing healthcare coverage for residents who may not otherwise have access to necessary medical services. With a focus on holistic health and community wellness, IEHP partners with local doctors and facilities to ensure comprehensive care for their members, supporting them with resources in mental health, fitness classes, and wellness education.

📋 Description

• Evaluate professional, high dollar, and outpatient/inpatient institutional claims • Determine coverage and payment levels • Evaluate and resolve provider disputes and appeals • Issue resolution letters • Process adjustment requests timely and accurately in accordance with standard procedures and regulatory guidelines • Participate in payment adjustment projects • Handle complex claims as assigned • Incorporate IEHP’s Quality Program goals, including 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 • 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 helpful • High School Diploma or GED required • 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

🏖️ Benefits

• State of the art fitness center on-site • Medical Insurance with Dental and Vision • Life, short-term, and long-term disability options • Career advancement opportunities and professional development • Wellness programs that promote a healthy work-life balance • Flexible Spending Account – Health Care/Childcare • CalPERS retirement • 457(b) option with a contribution match • Paid life insurance for employees • Pet care insurance