Claims Specialist I – Provider Claims

This is a fully remote position, open to applicants in California.

📋 Description

• Assess professional, high-value, and outpatient/inpatient institutional claims

• Evaluate coverage and determine payment levels

• Review and resolve provider disputes and appeals

• Generate resolution letters

• Timely and accurately process adjustment requests in line with standard procedures and regulatory guidelines

• Engage in payment adjustment initiatives

• Manage complex claims as assigned

• Align with IEHP’s Quality Program objectives, including HEDIS, CAHPS, and NCQA Accreditation

⛳️ Requirements

• At least four (4) years of experience in evaluating and processing institutional and professional medical claims

• Proficient in the following areas: Medical claims systems, ICD-10, and CPT coding

• Experience in reviewing medical authorizations

• Ability to interpret provider contract rates and determine medical benefit coverage

• Previous experience managing provider disputes, appeals, and claim adjustments

• Experience preferred in an HMO or Managed Care environment

• Medicare and/or Medi-Cal experience is a plus

• Background in a managed care or government payer setting is advantageous

• High School Diploma or GED is required

• Comprehensive understanding of claims industry and customer service standards

• Familiarity with ICD-9, ICD-10, CPT, HCPC coding, and general claims processing practices

• Strong analytical and problem-solving abilities

• Proficiency in Microsoft Office, particularly Advanced Microsoft Excel

• Effective written communication skills

• Capability to analyze data and interpret regulatory requirements

• Outstanding communication and interpersonal skills, strong organizational skills, and data entry proficiency are essential

• Typing speed of at least 45 wpm

• Excellent oral and written communication capabilities

• Ability to foster successful relationships across the organization

• Professional demeanor with telephone etiquette and a high level of patience

🏝️ Benefits

• On-site state-of-the-art fitness center

• Medical Insurance including Dental and Vision coverage

• Options for life, short-term, and long-term disability

• Opportunities for career advancement and professional development

• Wellness programs designed to promote a healthy work-life balance

• Flexible Spending Account for Health Care and Childcare

• CalPERS retirement plan

• 457(b) plan with contribution matching

• Paid life insurance for employees

• Pet care insurance