Lead Claims Processor

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 Lead Claims Processor is responsible for fulfilling the technical support needs of claims processing staff and handling complex claims. This includes but is not limited to; high dollar, dialysis, oncology/chemo, hospital exclusions and claim adjustments in an accurate and expedient manner. Additional duties include assistance with claim inventory control and regulatory audit needs. The Lead Claims Processor has direct communication with other internal and external business units in an effort to resolve claim issues or obtain process clarification.

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; we also aim to match our Team Members with the same energy by providing prime benefits and more.

• CalPERS retirement
• 457(b) option with a contribution match
• Generous paid time off- vacation, holidays, sick
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Paid life insurance for employees with additional options
• Short-term, and long-term disability options
• Pet care insurance
• Flexible Spending Account – Health Care/Childcare
• Wellness programs that promote a healthy work-life balance
• Career advancement opportunities and professional development
• Competitive salary with annual merit increase
• Team bonus opportunities

1. Support claim processing staff with technical questions and business rule clarification.
2. Assist Supervisor with inventory control and compliance monitoring.
3. Coordinate workflow needs relating to regulatory audits.
4. Assist with developing and mentoring of new team members.
5. Assist with the testing of new claim processing procedures.
6. Assist with the development and update of policies and procedures for the claims department.
7. Conduct refresher training of claims staff based on identified error trends.
8. Adjudicate complex professional and institutional claims.
9. Responsible for meeting modified performance measurement standards for productivity and accuracy.
10. Interface with other IEHP business units, vendors, and providers as needed.
11. Assist other business units as directed by Claims Supervisor
12. Adjudication of claim adjustments as assigned.
13. Participate in Claims Department Team Meetings, and other activities as needed.
14. This position provides support to all unit Team Members.

Education & Experience

• Minimum of four (4) years of experience in adjudicating inpatient and outpatient professional and institutional medical claims
• Experience preferably in an HMO or Managed Care setting
• Medicare and/or Medi-Cal experience preferred
• Prior experience in a lead role or customer service environment is a plus
• High School Diploma or GED required

Key Qualifications

• Must have a valid California Driver’s license
• Advanced knowledge of medical claim processing requirements
• Microcomputer skills, proficiency in Windows applications preferred. Excellent communication and interpersonal skills. Strong organizational skills required
• Professional demeanor

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

Telecommute