Lead Claims - Provider Claims

Date: Mar 18, 2023

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 9027 


Position Summary/Position


Under the direction of the Provider Claims Resolution & Recovery Supervisor, the Lead Claims – Provider Claims is responsible for fulfilling the technical support needs of claims support services staff and assist with research and handling of complex claims. This includes but is not limited to; high dollar, dialysis, oncology/chemo, hospital exclusions and claim adjustments in an accurate and expedient manner. Additional duties include assistance with preparing for audits both internal and external. The Lead has direct communication with other internal and external business units in an effort to resolve claim issues or obtain process clarification.

Major Functions (Duties and Responsibilities)


1. Supports Appeals staff with technical questions and business rule clarification.
2. Handle all Compliance related inquiries in a timely manner.
3. Coordinates workflow needs relating to regulatory audits.
4. Assist with developing and side-by-side training of new team and existing team members.
5. Interface with other IEHP business units, vendors, and providers as needed.
6. Assists other business units as directed by Claims Support Supervisor.
7. Adjudication of claim adjustments as assigned.
8. Participate in Claims Department Team Meetings, and other activities as needed.
9. Represent Claims department as subject matter expert during interdepartmental meetings.
10. This position provides support to all unit team members including in-office and telecommuters and has designated days working the in-office and days telecommuting.

Major Functions (Duties and Responsibilities) Cont

Supervisory Responsibilities

Leading: Guides Others

Experience Qualifications


Minimum of five (5) years of experience in adjudicating professional and institutional medical claims.

Preferred Experience


Leadership experience preferred. Experience with Medi-Cal and Medicare claims in an HMO or Managed Care setting preferred. 

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


Advanced knowledge of medical claim processing and auditing guidelines. Understanding of NCCI edits, provider contracts, Medi-Cal and Medicare regulatory guidelines along with claim system functionality and general claim processing practices.

Skills Requirement


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

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


Data entry involving computer keyboard and screens, filing, and copying of records and/or correspondence.

Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval. All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership.

Work Model Location


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

A reasonable salary expectation is between $53,892.80 and $68,702.40, based upon experience and internal equity.

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, designated as “Great Place to Work.” With a provider network of more than 5,000 and a team of more than 3,000 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and 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 stellar benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.

Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles