Claims Specialist I – Provider Claims

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

📋 Description

• Accountable for assessing professional, high-value, and outpatient/inpatient institutional claims while determining coverage and payment levels.

• Tasked with evaluating and resolving provider disputes and appeals.

• Responsible for issuing resolution letters.

• Ensuring timely and accurate processing of adjustment requests in accordance with standard procedures that guarantee compliance with regulatory guidelines.

• Additional responsibilities encompass payment adjustment projects and complex claims as assigned.

⛳️ 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, reviewing medical authorizations, interpreting provider contract rates, and determining medical benefit coverage.

• Previous experience in handling provider disputes, appeals, and claim adjustments.

• Preferably experienced in an HMO or Managed Care environment.

• Medicare and/or Medi-Cal experience is preferred.

• Familiarity with managed care or government payer settings is preferred.

• A high school diploma or GED is required.

• Must possess a valid California Driver's license.

• A comprehensive understanding of claims industry standards and customer service expectations.

• Knowledge of ICD-9, ICD-10, CPT, HCPC coding, and the general practices of claims processing.

• Strong analytical and problem-solving abilities.

• Proficient in Microsoft Office, especially Advanced Microsoft Excel.

• Strong written communication skills.

• Ability to analyze data and interpret regulatory requirements.

• Excellent communication and interpersonal skills, along with strong organizational abilities and data entry skills.

• Typing speed of at least 45 wpm.

• Exceptional oral and written communication skills.

• Capability to cultivate successful relationships throughout the organization.

• Professional demeanor is essential.

• Courteous telephone etiquette and a high degree of patience are required.

🏝️ Benefits

• Competitive salary.

• Telecommute schedule.

• CalPERS retirement plan.

• State-of-the-art fitness center on-site.

• Medical insurance that includes dental and vision coverage.

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

• Opportunities for career advancement and professional development.

• Wellness programs that support a healthy work-life balance.

• Flexible Spending Account for health care and childcare.

• Paid life insurance for employees.

• Pet care insurance.