Analyst I - Provider Claims

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 Provider Payment Resolution Manager, the Analyst I - Provider Claims is responsible for conducting quality audits of claims post payment, analyzing errors, determining root causes for appropriate classification, and validation of claims determination based on industry standards and regulations. The Analyst I - Provider Claims is responsible for providing ongoing feedback and analysis of the educational needs for providers and IEHP staff.

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. Responsible for executing resolutions of provider claim issues, which will include, but is not limited to, extensive claims data analysis, external departmental interactions, and provider communication.
2. Review high level claims issues requested by IEHP Contract Managers, Provider Service Representatives, Hospital Relations, and all other IEHP internal departments in addressing provider claim issues at meetings with the provider and/or provider office staff.
3. Provide education on the use of the IEHP website including claims and authorizations status, eligibility, and electronic submission of claims and direct deposit to IEHP Providers.
4. Provide clarification to IEHP Claims Department, Provider Services, Provider Call Center Leads, Supervisors and Management with any contractual questions and or interpretation.
5. Complete trend analysis and analyze reports provided by Providers and Claims/Configuration department. Analyze if call back action is needed to providers to assist with call volume maintenance in Provider Call Center.
6. Accountable for onboarding trainings for ancillary and specialist providers (new and existing) in compliance with NCQA standards, and DHCS and CMS regulatory requirements. Provider onboarding includes but is not limited to counseling/advising providers for various areas.
7. Communicate and provide education to Hospitals, PCP, Specialist and Ancillary Providers by providing information and assistance with billing and claim issues or concerns.
8. Provide review and payment clarification of claims and contractual incentives for providers as requested.
9. Prepare and participate in internal bi-weekly claims, configuration and claim support service meetings to review, discuss and resolve provider claim issues.
10. Participate in conference calls regarding claims and contracts to resolve provider disputes.
11. Coordinate, prepare and monitor special projects including data analysis and provider claim settlements as requested.
12. Manage System Change Request (SCR) for IEHP programs, coding updates, contractual exceptions by compiling and analyzing all data as well as facilitating documentation preparation for Chief Officer approval.
13. Assist with the development of the Provider Policy and Procedure Manual as requested.
14. Act as a Provider Advocate for IEHP providers, network specialist, ancillary providers and Hospitals, including but not limited to resolution of provider complaints, interpretation of benefits and the Division of Financial Responsibility.
15. Manage and Facilitate Administrative Decisions for claims reimbursement exceptions by analyzing reports, documenting request, and preparing data for Director and Chief approvals.
16. Any other duties as required ensuring Health Plan operations are successful.
17.  

Education & Requirements 

• Minimum two (2) years of experience in managed care setting along with understanding/knowledge of claims and configuration systems
• Two (2) years of experience in analyzing claims report, examining, and processing claims
• Bachelor’s degree from accredited institution required
  • In lieu of the required degree, a minimum of four (4) years of additional relevant work experience analyzing claims report, examining, and processing claims is required for this position. This experience is in addition to the minimum years listed in the Experience Requirements above

Key Qualifications

• Must have a valid California Driver's license
• Understating of DHCS, CMS, and DMHC guidelines.  Knowledge of UB04 and CMS 1500 billing criteria
• Strong analytical, auditing and problem-solving skills
• Effective communicator and collaborator
• Strong organizational skills and sound decision-making skills required
• Must be able to review cause and impact of problems and recommend realistic solutions both in writing and in meetings
• Proven ability to:
  • Build successful relationships across the organization
  • Be detailed-oriented
  • Communicate effectively at all organizational levels and in situations requiring instructing, persuading, consulting, and advising
  • Establish and maintain effective working relationships with all levels of staff and Providers
• Word processing, spreadsheet and database analysis involving computer keyboard and screens, automobile travel within the Inland Empire

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

This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA)