Evaluating professional, high dollar and outpatient/inpatient institutional claims while determining coverage and payment levels
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
Payment adjustment projects and complex claims as assigned

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 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