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IEHP रिवरसाइड और सैन बर्नार्डिनो काउंटियों में कम आय वाले व्यक्तियों और परिवारों की सेवा करने वाली एक क्षेत्रीय स्वास्थ्य योजना है। 1995 में स्थापित यह संस्था Medi-Cal, DualChoice और Covered California सहित कार्यक्रमों के माध्यम से कवरेज प्रदान करती है तथा सदस्यों को चिकित्सा सेवाओं से जोड़ने के लिए स्थानीय डॉक्टरों और स्वास्थ्य सुविधाओं के साथ काम करती है। इसका समुदाय-केंद्रित दृष्टिकोण मानसिक स्वास्थ्य सहायता, फिटनेस कार्यक्रमों और स्वास्थ्य संबंधी शिक्षा को भी शामिल करता है।
Claims Specialist I, Provider Claims
Review medical claims and provider disputes for IEHP, determining coverage, payment, and appropriate claim adjustments. Support timely resolution, accurate documentation, and compliant claims operations.
विवरण
- Assess professional and institutional medical claims to determine coverage and payment amounts.
- Process provider disputes within applicable state and federal deadlines.
- Investigate reported issues, adjust claims, and identify the causes of disputes.
- Prepare timely written responses to providers.
- Review and price complex edits across claim types to determine payment or denial outcomes.
- Complete required weekly reviews.
- Answer provider questions about submitted disputes.
- Track and prioritize assigned cases in IEHP’s provider dispute database.
- Keep current on claims procedures and participate in ongoing training.
- Research cases and gather information through verbal and written communication.
- Recommend process improvements based on trends and analysis of provider disputes.
- Work with other departments to resolve claim-related issues.
- Identify billing issues and report them to support provider education.
- Carry out other duties needed to support health plan operations.
- Protect the privacy and security of protected health information in line with IEHP policies and HIPAA requirements.
- Support IEHP Quality Program goals, including HEDIS, CAHPS, and NCQA accreditation.
आवश्यकताएँ
- At least four years of experience evaluating and processing institutional and professional medical claims.
- Proficiency with medical claims systems, ICD-10, and CPT coding.
- Experience reviewing medical authorizations.
- Ability to interpret provider contract rates and determine medical benefit coverage.
- Experience handling provider disputes, appeals, and claim adjustments.
- Experience in an HMO or managed care setting preferred.
- Medicare and/or Medi-Cal experience preferred.
- Experience in a managed care or government payer environment is helpful.
- High school diploma or GED required.
- Thorough understanding of the claims industry and customer service standards.
- Knowledge of ICD-9, ICD-10, CPT, HCPC coding, and general claims processing practices.
- Strong analytical and problem-solving skills.
- Proficiency with Microsoft Office and advanced Microsoft Excel.
- Written communication skills.
- Ability to analyze data and interpret regulatory requirements.
- Excellent communication and interpersonal skills.
- Strong organizational and data entry skills.
- Typing speed of at least 45 words per minute.
- Ability to build productive relationships across the organization.
- Professional demeanor.
- Telephone courtesy and a high degree of patience.
लाभ
- Competitive salary.
- On-site fitness center.
- Medical, dental, and vision insurance.
- Life, short-term disability, and long-term disability options.
- Career advancement opportunities and professional development.
- Wellness programs supporting work-life balance.
- Health care and childcare flexible spending accounts.
- CalPERS retirement plan.
- 457(b) plan with contribution matching.
- Employer-paid life insurance.
- Pet care insurance.
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