Claims Specialist I - Provider Claims

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Under the direction of the Provider Claims Resolution & Recovery Supervisor, the Claims Specialist I - Provider Claims is responsible for evaluating professional, high dollar and outpatient/inpatient institutional claims while determining coverage and payment levels. Responsible for evaluating and resolving provider disputes & appeals, issuing resolution letters, and processing adjustment requests timely and accurately in accordance with standard procedures that ensure compliance with regulatory guidelines. Additional responsibilities include payment adjustment projects and complex claims as assigned.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

• Minimum of four (4) years of experience evaluating and processing institutional and professional medical claims
• Proficiency in the following areas:
  • Medical claims system, ICD-10 and CPT coding
  • Reviewing medical authorizations
  • Provider contract rate interpretation, medical benefit coverage determination
  • Prior experience handling provider disputes, appeals and claim adjustments
• Experience preferably in and HMO or Managed Care setting
• Medicare and/or Medi-Cal experience preferred
• Experience in a managed care or government payer environment helpful
• High School Diploma or GED required

• A thorough understanding of claims industry and customer service standards
• Knowledge of ICD-9, ICD10, CPT, HCPC coding and general practices of claims processing
• Strong analytical and problem-solving skills
• Microsoft Office, Advanced Microsoft Excel
• Written communication skills
• Ability to analyze data and interpret regulatory requirements
• Excellent communication and interpersonal skills, strong organizational skills, and skilled in data entry required
• Typing a minimum of 45 wpm. Excellent oral and written communication skills
• Ability to build successful relationships across the organization
• Professional demeanor
• Telephone courtesy and high degree of patience

Telecommute (All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership

Sedentary work in an office environment

Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval. All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership