IEHP
IEHP
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 (California Remote)

Evaluate and resolve provider medical claims for Inland Empire Health Plan, including coverage and payment decisions, disputes, appeals, and adjustments.

विवरण

  • Review professional and institutional claims, including high-dollar and outpatient and inpatient claims
  • Determine coverage and payment levels
  • Resolve provider disputes and appeals
  • Prepare resolution letters
  • Process claim adjustment requests accurately and on time under standard procedures and regulatory guidelines
  • Contribute to payment adjustment projects
  • Manage complex claims as assigned
  • Support IEHP’s Quality Program goals, including HEDIS, CAHPS, and NCQA accreditation

आवश्यकताएँ

  • Bring at least four years of experience evaluating and processing institutional and professional medical claims
  • Be proficient with medical claims systems, ICD-10 and CPT coding, medical authorization review, provider contract rate interpretation, and medical benefit coverage decisions
  • Have prior experience managing provider disputes, appeals, and claim adjustments
  • Experience in an HMO or managed care setting is preferred
  • Medicare and/or Medi-Cal experience is preferred
  • Experience in a managed care or government payer environment is helpful
  • Have a high school diploma or GED
  • Understand claims operations and customer service standards
  • Know ICD-9, ICD-10, CPT, and HCPC coding and general claims processing practices
  • Demonstrate strong analytical and problem-solving skills
  • Be proficient with Microsoft Office and advanced Microsoft Excel
  • Have strong written communication skills
  • Be able to analyze data and interpret regulatory requirements
  • Have excellent communication and interpersonal skills, strong organization, and data entry skills
  • Type at least 45 words per minute
  • Have excellent oral and written communication skills
  • Build effective working relationships across the organization
  • Maintain a professional demeanor
  • Show telephone courtesy and patience.
  • State-of-the-art onsite fitness center
  • Medical, dental, and vision insurance coverage

लाभ

  • State-of-the-art onsite fitness center
  • Medical, dental, and vision insurance
  • Life insurance and short- and long-term disability options
  • Career advancement and professional development opportunities
  • Wellness programs supporting work-life balance
  • Flexible Spending Account for health care and childcare
  • CalPERS retirement plan
  • 457(b) plan with employer contribution match
  • Employer-paid life insurance
  • Pet care insurance

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