15d ago

Claims Specialist Quality Assurance I

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Legal & ComplianceClaims Specialist

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Quick Summary

Key Responsibilities

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

Technical Tools

Legal & ComplianceClaims Specialist

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 Quality Assurance (QA) Manager and Supervisor, the Claims Specialist Quality Assurance (CSQA) is responsible for ensuring the integrity of all data created and updated by the Claims Processing staff. The CSQA will utilize quality auditing tools, identify training needs, and define effective and efficient methods for accurate data entry and adjudication.

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.

What We Offer

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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
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

Responsibilities

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→Review and assess data reports and audit Claim Processor output to confirm payment accuracy and completeness of data entry.

→In-house expert for claims adjudication (Coordination of Benefits, pricing, contract interpretation, coding, and resolution of claims issues.)

→Ensure that all identified errors are corrected in an expedient manner.

→Be an active participant in the Claims Department’s initiatives and participate in the Claims Coaching process, MDI activities, etc.

→Assist with the processing of claims when necessary to address claims backlogs. Process approved Stop Loss reimbursements.

→Any other duties as required, to ensure the success of the organization.

→Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.

Requirements

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Two (2) years of experience in examining and processing institutional and professional claims
Medicare/Medi-Cal experience preferred
Experience in a managed care environment helpful
High school diploma or GED required

ICD-9/ ICD-10 and CPT coding and general practices of claims processing. Familiarity of Webstrat, Optum and CMS pricing
Excellent communication and interpersonal skills, strong organizational skills
Microcomputer skills, proficiency in Windows applications preferred
Professional demeanor

Telecommute (All IEHP positions approved for telecommute 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)

USD $25.90 - USD $33.02 /Hr.