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Temporary Claims Specialist II - Provider Claims
Job Description
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
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