Review and process provider dispute resolutions according to state and federal designated timeframes.
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.

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 an HMO or Managed Care setting.
Medicare and/or Medi-Cal experience preferred.
Experience in a managed care or government payer environment preferred.
High school diploma or GED required.
Must have a valid California Driver's license.
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.

Claims Specialist I – Provider Claims

Key skills