Claims Specialist II – Provider Claims

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

📋 Description

• Address the technical support requirements of both appeals and support personnel.

• Guarantee that appeals and call center operations are performed consistently and accurately.

• Manage escalated telephone inquiries related to claims.

• Provide assistance with cross-training as necessary.

• Execute complex claim adjustment projects.

• Process Provider Disputes in line with regulatory guidelines.

• Aid in conducting root cause analysis for detected claim issues.

• Collaborate with other business units to develop preventive measures.

• Assist in identifying training requirements.

• Recognize Lean improvements to unit workflows.

• Integrate IEHP’s Quality Program objectives, including HEDIS, CAHPS, and NCQA Accreditation.

⛳️ Requirements

• Minimum of four (4) years of experience in a managed care setting, specifically in claims processing, appeals & adjustments, and customer service, ideally within an HMO or Managed Care environment.

• Comprehensive knowledge of medical claim processing and customer service benchmarks.

• Experience with Medi-Cal/Medicare and previous experience in a leadership position is preferred.

• High school diploma or GED is required.

• Familiarity with the claim appeal process, provider contracts, claim system functionalities, and medical claim processing methodologies.

• Strong analytical capabilities and problem-solving skills.

• Proficiency in Microsoft Office and advanced skills in Microsoft Excel.

• Competence in microcomputer applications and proficiency in Windows applications is preferred.

• Exceptional oral and written communication abilities.

• Outstanding communication and interpersonal skills.

• Required customer service acumen and data entry capabilities.

• Typing speed of at least 45 words per minute.

• Ability to cultivate effective relationships throughout the organization.

• Professional demeanor coupled with strong organizational skills.

• High level of patience.

🏝️ Benefits

• Comprehensive health insurance options.

• Retirement savings plan with employer matching.

• Paid time off and flexible working hours.

• Opportunities for professional development and training.

• Supportive work environment focused on employee well-being.