Claims Processor III – Medi-Cal

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 Manager and Supervisor, the Claims Processor Level III is responsible for processing complex claims (professional and institutional). This includes but is not limited to; COB high dollar, dialysis, oncology/chemo, hospital exclusions and claim adjustments in an accurate and expedient manner, in addition to collaboration with, inter-departments to ensure member needs are met while simultaneously building strong peer relationships.

Key Responsibilities:

• Adjudicate complex professional and institutional inpatient/outpatient claims.
• Meet Regulatory Compliance Regulations on turnaround times and claim payments.
• Assist with training and mentoring of new Team Members.
• Must be able to make a sound determination if claim is eligible for payment or denial.
• Complete claim using multiple source documents to verify data and/or use additional information to adjudicate claim.
• Assist with the testing of new claim processing procedures or projects.
• Read and interpret Medi-Cal/Medicare Fee Schedules.
• Responsible for meeting performance measurement standards for productivity and accuracy.
• Adjudication of claim adjustments.
• Review and correct claims involving data integrity issues.
• Interface with other IEHP Departments, when necessary, regarding claims issues.
• Participate in Claims Department Team Meetings, and other activities as needed.
• Any other duties as required to ensure the Health Plan operations are successful.
  
  
  

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
  
  
  

Education & Experience

• Three (3) years experience in adjudicating medical claims.
• High School Diploma or GED required.
  
  
  

Key Qualifications

• ICD-9 and CPT coding and general practices of claims processing.
• Excellent communication and interpersonal skills, strong organizational skills required.
  
  
  

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