Provider Claims Specialist - Remote - Southern CA

Pay range: $26-$28/hr

Kinetic Personnel Group is recruiting for a Provider Claims Specialist 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. A permanent job includes a pay rate increase, CalPERS pension, ~10% yearly bonus, 457b (~6% contribution) and excellent government benefits including PTO schedule (year 1).

Provider Claims Specialist 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.

Additionally, will help perform root cause analysis for identified claim issues and interface with other business units to establish preventive solutions. 

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.

Requirements:

• 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

• A thorough understanding of medical claim processing and customer service standards

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

• High school diploma or GED required

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