Lead Claims - Provider Claims

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

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

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