Claims Processor II

Overview:

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Under the direction of the Claims Production Manager and Supervisor, the Claims Processor Level II will be processing outpatient professional and institutional claims. This includes but is not limited to; lab, radiology, ambulance, behavior health, outpatient COB, dialysis, oncology/chemo, hospital exclusions etc., in an accurate and expedient manner.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary.
• Hybrid 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
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

1. Responsible for non-delegated provider claims verification and adjudication.
2. Adjudicate all professional and outpatient claims including COB, denials, and reduction in service notifications.
3. Meet Regulatory Compliance Regulations on turnaround times and claim payments.
4. Read and interpret Medi-Cal/Medicare Fee Schedules.
5. Must be able to make a sound determination if claim is eligible for payment or denial.
6. Interface with other IEHP Departments, when necessary, regarding claims issues.
7. Participate in Claims Department staff meetings, and other activities as needed.
8. Responsible for meeting the performance measurement standards for productivity and accuracy.
9. Any other duties as required to ensure the Health Plan operations are successful.

Education & Requirements 

• Minimum of two (2) years of experience adjudicating outpatient professional and/or institutional claims preferably in an HMO or Managed Care setting
• Processing of Medicare, Medi-Cal, or Commercial claims required
• Proficient in rate applications for Medi-Cal and/or Medicare pricers
• High school diploma or GED required

Key Qualifications

• ICD-9 and CPT coding and general practices of claims processing
• Prefer knowledge of capitated managed care environment
• Microcomputer skills, proficiency in Windows applications preferred
• Excellent communication and interpersonal skills, strong organizational skills
• Professional demeanor
• Must be computer literate, maintain good attendance, and have the right attitude and discipline to work from home
• 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

Start your journey towards a thriving future with IEHP and apply TODAY!

Telecommute