Claims Specialist I – Provider Claims
Job Description:
• 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
• 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
Requirements:
• 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
• 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
• High School Diploma or GED required
• A thorough understanding of claims industry and customer service standards
• Knowledge of ICD-9, ICD10, CPT, HCPC coding and general practices of claims processing
• 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
• Ability to build successful relationships across the organization
• Professional demeanor
• Telephone courtesy and high degree of patience
Benefits:
• Competitive salary
• Telecommute schedule
• CalPERS retirement
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account – Health Care/Childcare
• Paid life insurance for employees
• Pet care insurance
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• 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
• 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
Requirements:
• 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
• 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
• High School Diploma or GED required
• A thorough understanding of claims industry and customer service standards
• Knowledge of ICD-9, ICD10, CPT, HCPC coding and general practices of claims processing
• 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
• Ability to build successful relationships across the organization
• Professional demeanor
• Telephone courtesy and high degree of patience
Benefits:
• Competitive salary
• Telecommute schedule
• CalPERS retirement
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account – Health Care/Childcare
• Paid life insurance for employees
• Pet care insurance
Apply tot his job
Apply To this Job