Claims Specialist I - Provider Claims (Remote)

Date: Jul 19, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5404 


Position Summary/Position


Under the direction of the Provider Claims Resolution & Recovery Supervisor, the Claims Specialist I - Provider Claims is responsible for evaluating professional, high dollar and outpatient/inpatient institutional claims while determining coverage and payment levels. Responsible for 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. Additional responsibilities include payment adjustment projects and complex claims as assigned.

Major Functions (Duties and Responsibilities)


1. Review and process provider dispute resolutions according to state and federal designated timeframes.
2. Research reported issues; adjust claims and determine the root cause of the dispute.
3. Draft written responses to providers in a professional manner within required timelines.
4. Independently review and price complex edits related to all claim types to determine the appropriate handling for each including payment or denial.
5. Complete the required number of weekly reviews deemed appropriate for this position.
6. Respond to provider inquiries regarding disputes that have been submitted.
7. Maintain, track, and prioritize assigned caseload through IEHP’s provider dispute database to ensure timely completion.
8. Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed.
9. Communicate with a variety of people, both verbally and in writing, to perform research, gather information related to the case that is under review.
10. Recommend opportunities for improvement identified through the trending and analysis of all incoming PDRs.
11. 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.

Supervisory Responsibilities

Leading: Self

Experience Qualifications


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.

Preferred Experience


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 helpful.

Education Qualifications


High school diploma or GED required.

Preferred Education

Professional Certification

Professional Licenses

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement


A thorough understanding of claims industry and customer service standards. Knowledge of ICD-9, ICD10, CPT, HCPC coding and general practices of claims processing. 

Skills Requirement


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.

Abilities Requirement


Ability to build successful relationships across the organization. Professional demeanor. Telephone courtesy and high degree of patience.

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions


Sedentary work in an office environment.

Physical Requirements

Keyboarding: Traditional - FREQUENTLY
Keyboarding: Other - FREQUENTLY
Use of computer mouse - FREQUENTLY
Hearing: One-on-One - FREQUENTLY
Hearing: In a group - FREQUENTLY
Hearing: Over the Telephone/Cell Phone - FREQUENTLY
Hearing: Conference Speakers/Video Calls/Radio Calls - FREQUENTLY
Near Visual Acuity - FREQUENTLY
Communicate: Information/ideas verbally - FREQUENTLY
Alternate Sit/Stand or Walk at Will - FREQUENTLY
Turning/rotation of wrist or hand - FREQUENTLY
Perform complex and varied tasks - FREQUENTLY
Develop and maintain positive work relationships - CONSTANTLY
Regular contacts: co-workers, supervisor - FREQUENTLY
Decision-making - FREQUENTLY
Lead/Influence Others - FREQUENTLY
Work review - FREQUENTLY
Rapid Pace of work - FREQUENTLY
Control of work pace - FREQUENTLY
Problem Solving - FREQUENTLY
Understand and follow direction - FREQUENTLY
Regular and reliable attendance - CONSTANTLY


Starting Salary: $40,601.60  - $50,752.00  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles