Claims Specialist - Provider Claims

Pay range is $26-$28/hr

Kinetic Personnel Group is recruiting for a Claims Specialist - Provider Claims for a $5 billion/year Public Health Plan in the Ontario California area. This government agency is renowned for the work it does in the community and being a great place to work.

This position is remote with occasional meetings in the office. Candidates should be local to Southern California. This will be a temporary position initially, with the possibility of converting to a permanent government job after 6 months. Pay rate can increase,and includes CalPERS pension, ~10% yearly bonus, 457b (~6% contribution) and excellent benefits including excellent PTO/Holiday schedule (year one).

The Claims Specialist– 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.

Job duties:

1. Review and process provider dispute resolutions according to state and federal designated timeframes.

2. Review and assist with applying identified refunds submitted by the CART team.

3. Research reported issues; adjust claims and determine the root cause of the dispute.

4. Draft written responses to providers in a professional manner within required timelines.

5. Independently review and price complex edits related to all claim types to determine the appropriate handling for each including payment or denial.

6. Complete the required number of weekly reviews deemed appropriate for this position. 

7. Respond to provider inquiries regarding disputes that have been submitted.

8. Maintain, track, and prioritize assigned caseload through provider dispute database to ensure timely completion.

9. Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed.

10. Communicate with a variety of people, both verbally and in writing, to perform research, gather information related to the case that is under review.

11. Recommend opportunities for improvement identified through the trending and analysis of all incoming PDRs.

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

• Medi-Cal/Medicare experience and prior experience in a lead role preferred

• High school diploma or GED required (will be verified)

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