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Claims Auditing Specialist (Institutional) Telecommute

Company: Inland Empire Health Plans
Location: Rancho Cucamonga
Posted on: June 6, 2021

Job Description:

Job Requisition ID: 4476

Position Summary/Position

Under the direction of the Claims Quality Assurance (QA) Manager and Supervisor, the Claims Specialist Quality Assurance I (CSQA)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.

Major Functions (Duties and Responsibilities)

1.Review and assess data reports and audit Claim Processor output to confirm payment accuracy and completeness of data entry.
2.In-house expert for claims adjudication (Coordination of Benefits, pricing, contract interpretation, coding, and resolution of claims issues.)
3.Ensure that all identified errors are corrected in an expedient manner.
4.Be an active participant in the Claims Departments initiatives and participate in the Claims Coaching process, MDI activities, etc.
5.Assist with the processing of claims when necessary to address claims backlogs. Process approved Stop Loss reimbursements.

Supervisory Responsibilities

Leading: Self

Experience Qualifications

Two (2) years experience in examining and processing institutional and professional claims. Experience in a managed care environment helpful with familiarity of Webstrat, Optum and CMS pricing.

Preferred Experience

Medicare/Medi-Cal experience preferred.

Education Qualifications

High school diploma or GED required.

Preferred Education

Professional Certification

Professional Licenses

Drivers License Required


Knowledge Requirement

ICD-9/ ICD-10 and CPT coding and general practices of claims processing.

Skills Requirement

Microcomputer skills, proficiency in Windows applications preferred. Excellent communication and interpersonal skills, strong organizational skills.

Abilities Requirement

Professional demeanor.

Commitment to Team Culture

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

Physical Requirements

Gross Manipulation - CONSTANTLY
Keyboarding: 10-Key - CONSTANTLY
Keyboarding: Traditional - CONSTANTLY
Use of computer mouse - CONSTANTLY
Fine manipulation - CONSTANTLY
Use hands/fingers to handle or feel - CONSTANTLY
Side to side motion of the wrist - CONSTANTLY
Turning/rotation of wrist or hand - CONSTANTLY
Up and down flexion of wrist - CONSTANTLY
Regular and reliable attendance - CONSTANTLY
Develop and maintain positive work relationships - CONSTANTLY
Problem Solving - FREQUENTLY

Starting Salary:$45,468.80 -$56,846.40

Pay rate will commensurate with experience

Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, were ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.

Keywords: Inland Empire Health Plans, Rancho Cucamonga , Claims Auditing Specialist (Institutional) Telecommute, Other , Rancho Cucamonga, California

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