Claims Specialist II – Provider Claims

Job Description:

• Fulfill the technical support needs of appeals and support staff
• Ensure appeals and call center tasks are conducted consistently and accurately
• Handle escalated claim-related telephone inquiries
• Assist with cross-training as needed
• Perform complex claim adjustment projects
• Process Provider Disputes in accordance with regulatory requirements
• Help perform root cause analysis for identified claim issues
• Interface with other business units to establish preventive solutions
• Help identify training needs
• Identify Lean improvements to unit workflows
• Incorporate IEHP’s Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation

Requirements:

• Four (4) years of experience in a managed care environment in the area of claims processing; appeals & adjustments, and customer service, preferably in an HMO or Managed Care setting
• A thorough understanding of medical claim processing and customer service standards
• Medi-Cal/Medicare experience and prior experience in a lead role preferred
• High school degree or GED required
• Understanding of claim appeal process, provider contracts, claim system functionality and medical claim processing practices
• Strong analytical and problem-solving skills
• Microsoft Office and Advanced Microsoft Excel
• Microcomputer skills and proficiency in Windows applications preferred
• Excellent oral and written communication skills
• Excellent communication and interpersonal skills
• Customer service skills and data entry required
• Typing a minimum of 45 wpm
• Ability to build successful relationships across the organization
• Professional demeanor and strong organization skills
• High degree of patience

Benefits: