Claims Specialist I Provider Claims

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

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. Further responsibilities include payment adjustment projects and complex claims as assigned, in addition to collaboration with, inter-departments to ensure member needs are met while simultaneously building strong peer relationships.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary.
• Hybrid schedule.
• CalPERS retirement.
• 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

Education & Experience

• 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.

Key Qualifications

• Yes, 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. 
• Ability to analyze data and interpret regulatory requirements.
• Excellent communication and interpersonal skills, strong organizational skills, and skilled in data entry required.
• Proficiency in Microsoft Office, Advanced Microsoft Excel. 
• Typing a minimum of 45 wpm.

Start your journey towards a thriving future with IEHP and apply TODAY!