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Claims Auditing Specialist (Institutional) Telecommute

Date: Mar 24, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 4476 

 

Position Summary/Position

 

Under the direction of the Claims Quality Assurance (QA) Manager and Supervisor, the Claims Specialist Quality Assurance I (CSQA)  responsible  for  ensuring  the  integrity  of  all  data  created  and updated  by the Claims Processing staff. The CSQA will utilize quality auditing tools, identify training needs, and define effective and efficient methods for accurate data entry and adjudication.

Major Functions (Duties and Responsibilities)

 

1. Review  and  assess  data  reports  and  audit  Claim  Processor  output  to  confirm  payment accuracy and completeness of data entry.
2. In-house expert for claims adjudication (Coordination of Benefits, pricing, contract interpretation, coding, and resolution of claims issues.)
3. Ensure that all identified errors are corrected in an expedient manner.
4. Be an active participant in the Claims Department’s initiatives and participate in the Claims Coaching process, MDI activities, etc.
5. Assist with the processing of claims when necessary to address claims backlogs. Process approved Stop Loss reimbursements.

Supervisory Responsibilities

Leading: Self

Experience Qualifications

 

Two  (2)  years  experience  in  examining  and  processing institutional and  professional claims. Experience in a managed care environment helpful with familiarity of Webstrat, Optum and CMS pricing.

Preferred Experience

 

Medicare/Medi-Cal experience preferred.

Education Qualifications

 

High school diploma or GED required.

Preferred Education

Professional Certification

Professional Licenses

Drivers License Required

No

Knowledge Requirement

 

ICD-9/ ICD-10 and CPT coding and general practices of claims processing.

Skills Requirement

 

Microcomputer skills, proficiency in Windows applications preferred. Excellent communication and interpersonal skills, strong  organizational skills.

Abilities Requirement

 

Professional demeanor.

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

Physical Requirements

Sitting - CONSTANTLY
Gross Manipulation - CONSTANTLY
Keyboarding: 10-Key - CONSTANTLY
Keyboarding: Traditional - CONSTANTLY
Use of computer mouse - CONSTANTLY
Fine manipulation - CONSTANTLY
Use hands/fingers to handle or feel - CONSTANTLY
Side to side motion of the wrist - CONSTANTLY
Turning/rotation of wrist or hand - CONSTANTLY
Up and down flexion of wrist - CONSTANTLY
Regular and reliable attendance - CONSTANTLY
Develop and maintain positive work relationships - CONSTANTLY
Indoors - CONSTANTLY
Problem Solving - FREQUENTLY

 

Starting Salary: $45,468.80  - $56,846.40  

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