Claims Specialist II - Rancho Cucamonga - Alura Workforce Solutions

    Alura Workforce Solutions
    Alura Workforce Solutions Rancho Cucamonga

    1 week ago

    Description
    POSITION
    Claims Specialist II
    Position Type: Temporary
    Schedule: M-F, 8:00 am - 5:00 pm
    Assignment Length: Approximately 6-Months, possibly longer.
    DESCRIPTION
    The Claims Specialist II - Provider Claims is responsible for fulfilling the technical support needs of appeals and support staff, while ensuring that appeals and call center tasks are conducted consistently and accurately. Additional responsibilities include handling escalated claim-related telephone inquiries, assisting with cross-training as needed, performing complex claim adjustment projects, and processing Provider Disputes in accordance with regulatory requirements.
    Additionally, the Claims Specialist II - Provider Claims will help perform root cause analysis for identified claim issues and interface with other business units to establish preventive solutions. The Claims Specialist II - Provider Claims will help identify training needs and identify Lean improvements to all unit workflows.
    • Review and process provider dispute resolutions according to state and federal designated timeframes.
    • Review and assist with applying identified refunds submitted by the CART team.
    • Research reported issues; adjust claims and determine the root cause of the dispute.
    • Draft written responses to providers in a professional manner within required timelines.
    • Independently review and price complex edits related to all claim types to determine the appropriate handling for each including payment or denial.
    • Complete the required number of weekly reviews deemed appropriate for this position.
    • Respond to provider inquiries regarding disputes that have been submitted.
    • Maintain, track, and prioritize assigned caseload through IEHP's provider dispute database to ensure timely completion.
    • Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed.
    • Communicate with a variety of people, both verbally and in writing, to perform research, gather information related to the case that is under review.
    • Recommend opportunities for improvement identified through the trending and analysis of all incoming PDRs.
    • Coordinate with other departments as necessary to facilitate resolution of claim related issues. Identify and report claim related billing issues to various departments for provider education
    • Any other duties as required to ensure Health Plan operations are successful.
    • Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.
    REQUIREMENTS
    • Four (4) years of experience in a managed care environment in the area of claims processing; appeals & adjustments, and customer service, preferably in an HMO or Managed Care setting
    • A thorough understanding of medical claim processing and customer service standards
    • Medi-Cal/Medicare experience and prior experience in a lead role preferred
    • High school diploma or GED required
    Key Qualifications
    • Must have a valid California Driver's license
    • Understanding of claim appeal process, provider contracts, claim system functionality and medical claim processing practices
    • Strong analytical and problem-solving skills
    • Microsoft Office, Advanced Microsoft Excel
    • Microcomputer skills, proficiency in Windows applications preferred
    • Excellent oral and written communication skills
    • Excellent communication and interpersonal skills
    • Customer service skills and skilled in data entry required
    • Typing a minimum of 45 wpm
    • Ability to build successful relationships across the organization
    • Professional demeanor and strong organization skills
    • High degree of patience

  • Claims Specialist

    1 month ago

    Only for registered members Rancho Cucamonga, CA Remote job

    About Us Inland Empire Health Plan (IEHP) is a not-for-profit public health plan supporting over 1.5 million residents in Riverside and San Bernardino Counties through Medicaid, Medicare-Medicaid (IEHP DualChoice), and Covered California plans. · Analyzing, managing, and investig ...

  • Claims Specialist

    1 month ago

    Only for registered members Rancho Cucamonga, CA

    What you can expectFind 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 experienceUnder the direction of the Covered California Claims (CCA) Manager, the CCA Claims Special ...

  • Claims Specialist

    1 month ago

    Only for registered members Rancho Cucamonga $25.90 - $33.02 (USD)

    Under the direction of the Covered California Claims (CCA) Manager, the CCA Claims Specialist is responsible for analyzing and managing healthcare claims that require in-depth research. · Adjusting first-pass and post-pay claims. · Collaborating with internal stakeholders. · ...

  • Claims Specialist

    1 month ago

    Only for registered members Rancho Cucamonga $25.90 - $33.02 (USD)

    The CCA Claims Specialist is responsible for analyzing and managing complex healthcare claims. · Analyzing and managing complex and high-dollar healthcare claims. · ...

  • Liability Claims Specialist

    1 month ago

    Only for registered members Rancho Cucamonga Part time $24.91 - $40.17 (USD)

    The Liability Claims Specialist manages non-complex and non-problematic Liability claims under direct supervision of a senior claims professional. This role aims to achieve optimal outcomes for both CorVel and our clients.Manages non-complex and non-problematic medical only claim ...

  • CA Claims Specialist SIP

    13 hours ago

    Only for registered members Rancho Cucamonga, California, , United States

    The Claims Specialist manages workers' compensation claims within delegated limited authority to best possible outcome. · ...

  • CA Claims Specialist SIP

    1 day ago

    Only for registered members Rancho Cucamonga $25.48 - $41.09 (USD)

    The Claims Specialist manages lower-level workers' compensation claims within delegated authority to best possible outcome under the direct supervision of a senior claims professional supporting the goals of claims department and of CorVel. This is a remote position. · Bachelor's ...

  • CA WC Claims Specialist

    1 month ago

    Only for registered members Rancho Cucamonga, CA Remote job

    The Claims Specialist manages workers' compensation claims within delegated limited authority to best possible outcome.This is a remote position. · ...

  • CA Senior Claims Specialist

    4 weeks ago

    Only for registered members Rancho Cucamonga $28.69 - $46.21 (USD)

    The Senior Claims Specialist manages within company standards and best practices complex and problematic, high visibility workers' compensation claims. · ...

  • CA Claims Specialist SIP

    1 day ago

    Only for registered members Rancho Cucamonga, CA Remote job

    The Claims · Specialist manages within company best practices lower-level claims to the best possible outcome under direct supervision of a senior claims professional supporting goals of claims department and CorVel.This is a remote position. · ...

  • CA Senior Claims Specialist (4850)

    2 weeks ago

    Only for registered members Rancho Cucamonga, California, , United States

    The Senior Claims Specialist handles complex and high-profile Workers' Compensation claims following company standards. · This is a remote position. Candidate must reside in California. ...

  • CA Senior Liability Claims Specialist

    2 weeks ago

    Only for registered members Rancho Cucamonga, California, , United States

    The Senior Liability Claims Specialist manages mid to complex Auto and/or General Liability claims. This role aims to achieve optimal outcomes for both CorVel and our clients. · Receives claims, confirms policy coverage and acknowledgment of the claim · Determines validity and co ...

  • CA WC Senior Claims Specialist

    1 week ago

    Only for registered members Rancho Cucamonga, California, , United States

    The Senior Claims Specialist handles complex and high-profile Workers' Compensation claims following company standards. This role works closely with case managers and attorneys, manages subrogation, and negotiates settlements. · This is a remote position. ...

  • Medical Only Claims Specialist SIP

    1 week ago

    Only for registered members Rancho Cucamonga, California, , United States

    The Medical Only Claims Specialist manages non-complex and non-problematic, medical only claims and minor lost-time workers' compensation claims under close supervision. · ...

  • Medical Only Claims Specialist SIP

    1 month ago

    Only for registered members Rancho Cucamonga, CA Remote job

    The Medical Only Claims Specialist manages non-complex and non-problematic medical only claims and minor lost-time workers' compensation claims under close supervision supporting the goals of the Claims Department and of CorVel. · This is a remote position.Bachelor's degree or a ...

  • CA Senior Liability Claims Specialist

    1 week ago

    Only for registered members Rancho Cucamonga, California, , United States

    The Senior Liability Claims Specialist manages mid to complex Auto and/or General Liability claims. This role aims to achieve optimal outcomes for both CorVel and our clients. · • Receives claims · • Determines validity and compensability of the claim · • Investigates claims and ...

  • CA Senior WC Claims Specialist

    1 month ago

    Only for registered members Rancho Cucamonga $28.69 - $46.21 (USD)

    The Senior WC Claims Specialist handles complex and high-profile Workers' Compensation claims following company standards. · This is a remote position, but candidate must reside in California and have their Self-Insured Certificate. · ...

  • CA WC Senior Claims Specialist

    1 week ago

    Only for registered members Rancho Cucamonga $29.35 - $47.28 (USD)

    The Senior Claims Specialist handles complex and high-profile Workers' Compensation claims following company standards. · Receives claim, confirms policy coverage and acknowledgement of the claimDetermines validity and compensability of the claim by investigating and gathering in ...

  • CA WC Senior Claims Specialist

    1 day ago

    Only for registered members Rancho Cucamonga $29.35 - $47.28 (USD)

    The Senior Claims Specialist handles complex and high-profile Workers' Compensation claims following company standards. · This role works closely with case managers and attorneys, · manages subrogation, and negotiates settlements. · ...

  • CA Senior Liability Claims Specialist

    1 month ago

    Only for registered members Rancho Cucamonga $28.69 - $46.21 (USD)

    The Senior Liability Claims Specialist manages mid to complex Auto and/or General Liability claims. This role aims to achieve optimal outcomes for both CorVel and our clients. · This is a remote position. · ...

  • CA WC Senior Claims Specialist

    1 week ago

    Only for registered members Rancho Cucamonga $29.35 - $47.28 (USD)

    The Senior Claims Specialist handles complex and high-profile Workers' Compensation claims following company standards. This role works closely with case managers and attorneys, manages subrogation, and negotiates settlements. · This is a remote position.Receives claim, confirms ...

Jobs
>
Claims specialist ii
>
Jobs for Claims specialist ii in Rancho Cucamonga