Claims Specialist II - Provider Claims 26-00029

The Claims Specialist II – Provider Claims is responsible for fulfilling the technical support needs of appeals and support staff, while ensuring that appeals and call center tasks are conducted consistently and accurately. Additional responsibilities include handling escalated claim-related telephone inquiries, assisting with cross-training as needed, performing complex claim adjustment projects, and processing Provider Disputes in accordance with regulatory requirements.

Additionally, the Claims Specialist II – Provider Claims will help perform root cause analysis for identified claim issues and interface with other business units to establish preventive solutions. The Claims Specialist II – Provider Claims will help identify training needs and identify Lean improvements to all unit workflows.

1. Review and process provider dispute resolutions according to state and federal designated timeframes.
2. Review and assist with applying identified refunds submitted by the CART team.
3. Research reported issues; adjust claims and determine the root cause of the dispute.
4. Draft written responses to providers in a professional manner within required timelines.
5. Independently review and price complex edits related to all claim types to determine the appropriate handling for each including payment or denial.
6. Complete the required number of weekly reviews deemed appropriate for this position.
7. Respond to provider inquiries regarding disputes that have been submitted.
8. Maintain, track, and prioritize assigned caseload through IEHP's provider dispute database to ensure timely completion.
9. Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed.
10. Communicate with a variety of people, both verbally and in writing, to perform research, gather information related to the case that is under review.
11. Recommend opportunities for improvement identified through the trending and analysis of all incoming PDRs.
12. 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
13. Any other duties as required to ensure Health Plan operations are successful.
14. Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.

• Four (4) years of experience in a managed care environment in the area of claims processing; appeals & adjustments, and customer service, preferably in an HMO or Managed Care setting
• A thorough understanding of medical claim processing and customer service standards
• Medi-Cal/Medicare experience and prior experience in a lead role preferred
• High school diploma or GED required

Key Qualifications

• Must have a valid California Driver's license
• Understanding of claim appeal process, provider contracts, claim system functionality and medical claim processing practices
• Strong analytical and problem-solving skills
• Microsoft Office, Advanced Microsoft Excel
• Microcomputer skills, proficiency in Windows applications preferred
• Excellent oral and written communication skills
• Excellent communication and interpersonal skills
• Customer service skills and skilled in data entry required
• Typing a minimum of 45 wpm
• Ability to build successful relationships across the organization
• Professional demeanor and strong organization skills
• High degree of patience