Claims Processor Iii- Medi-Cal (Remote)

Position Summary/Position

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.

Major Functions (Duties and Responsibilities)

1. Adjudicates complex professional and institutional claims.
2. Assist with training and mentoring of new team members.
3. Assist with the testing of new claim processing procedures or projects.
4. Responsible for meeting performance measurement standards for productivity and accuracy.
5. Adjudication of claim adjustments.
6. Review and correct claims involving data integrity issues.
7. Interface with other IEHP Departments, when necessary, regarding claims issues.
8. Participate in Claims Department Team Meetings, and other activities as needed.

Major Functions (Duties and Responsibilities) Cont

Supervisory Responsibilities

Experience Qualifications

Three (3) years experience in adjudicating medical claims.

Preferred Experience

Experience in adjudicating medical claims: professional and institutional preferably in and HMO or Managed Care setting. 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 and CPT coding and general practices of claims processing.

Skills Requirement

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

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

Data entry involving computer keyboard and screens, filing and copying of records and/or correspondence.

Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval. All IEHP positions approved for telecommute or hybrid 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.

Work Model Location

Physical Requirements