Temporary Claims Specialist II - Provider Claims

Temporary Claims Specialist II - Provider Claims

Assignment Length: Six Months

Work Location: 10801 6th St STE 120, Rancho Cucamonga, CA 91730

Key Responsibilities

• Review and process provider dispute resolutions according to state and federal designated timeframes.
• Review and assist with applying identified refunds submitted by the CART team.
• Research reported issues; adjust claims and determine the root cause of the dispute.
• Draft written responses to providers in a professional manner within required timelines.
• Independently review and price complex edits related to all claim types to determine the appropriate handling for each including payment or denial.
• Complete the required number of weekly reviews deemed appropriate for this position.
• Respond to provider inquiries regarding disputes that have been submitted.
• Maintain, track, and prioritize assigned caseload through IEHP's provider dispute database to ensure timely completion.
• Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed.
• Communicate with a variety of people, both verbally and in writing, to perform research, gather information related to the case that is under review.
• Recommend opportunities for improvement identified through the trending and analysis of all incoming PDRs.
• Coordinate with other departments as necessary to facilitate resolution of claim related issues. Identify and report claim related billing issues to various departments for provider education
• Any other duties as required to ensure Health Plan operations are successful.
• Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.

Qualifications

• Education & 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 diploma or GED required

Key Qualifications

• Must have a valid California Driver's license
• Understanding of claim appeal process, provider contracts, claim system functionality and medical claim processing practices
• Strong analytical and problem-solving skills
• Microsoft Office, Advanced Microsoft Excel
• Microcomputer skills, proficiency in Windows applications preferred
• Excellent oral and written communication skills
• Excellent communication and interpersonal skills
• Customer service skills and skilled in 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