Claims Research Specialist

Job not on LinkedIn

🔥 3 hours ago

🏄 California – Remote

🏄 California – Remote

💵 $30 - $42 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔬 Research Analyst

🚫👨‍🎓 No degree required

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Sharp HealthCare

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1946

🏥 Healthcare

🧘 Wellness

Healthcare • Nursing • Wellness

Sharp HealthCare is a healthcare organization dedicated to providing high-quality medical services to patients and families. With a commitment to innovation, safety, and excellence, Sharp HealthCare offers a range of career opportunities in nursing, clinical support, administration, and various medical specialties. The organization emphasizes a collaborative work environment and is recognized for its nursing excellence, aiming to advance the science of medicine alongside compassionate patient care.

📋 Description

• Research and resolve complex claims processing, billing, provider claims adjudication, and payment dispute issues • Correct errors promptly to improve provider and customer satisfaction • Respond to provider and internal department inquiries via phone, mail, or fax • Research and resolve provider payment disputes and appeals • Investigate claim status and explain contract status, financial risk, and payment methodologies • Educate providers about contracts and notify them when errors occur • Track and trend issues and recommend improvements to contract terms, contract setup, and claims adjudication policies • Conduct one-time rate negotiations referred by the claims department • Document negotiation results and forward claims for timely payment • Communicate with internal departments and external customers by telephone, email, and written communication • Develop professional relationships with internal departments, vendors, providers, employers, brokers, and other customers • Participate in special projects, work groups, proposals, audits, and backup support • Assist with preparation of reinsurance filings • Maintain organized work areas, files, tools, resources, and reference materials • Use plan policies, benefit agreements, regulations, provider manuals, fee schedules, databases, contracts, and applications to support departmental needs

🎯 Requirements

• Minimum of 2 years of experience in a health plan or other health care setting, including claims processing, customer service call center, provider contracting and relations, and medical billing • Experience resolving issues under tense and stressful circumstances • Experience with electronic mail, word processing, spreadsheets, and database programs • Employees must reside in California for this remote position • Thorough understanding of managed care principles, models, and reimbursement methodologies • Familiarity with DMHC and DHS regulations • Familiarity with CPT and ICD-10-CM diagnosis and procedure codes and other billing guidelines • H.S. Diploma or Equivalent listed under preferred qualifications • Experience with Managed Care application preferred • CPC-H, CPC-P, CPC, and CCS certifications preferred • Certification in medical terminology and/or medical billing/coding preferred

🏖️ Benefits

• Primarily remote work / work from home • Full-time employment • Day shift schedule • No on-call requirement • Equal opportunity/affirmative action employment