Analyst I Provider Claims
Posted 2025-05-18Overview:
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 IEHPs Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.
Additional Benefits:
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
Key Responsibilities: 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. 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. 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. Provide clarification to IEHP Claims Department, Provider Services, Provider Call Center Leads, Supervisors and Management with any contractual questions and or interpretation. 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. 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. Communicate and provide education to Hospitals, PCP, Specialist and Ancillary Providers by providing information and assistance with billing and claim issues or concerns. Provide review and payment clarification of claims and contractual incentives for providers as requested. Prepare and participate in internal bi-weekly claims, configuration and claim support service meetings to review, discuss and resolve provider claim issues. Participate in conference calls regarding claims and contracts to resolve provider disputes. Coordinate, prepare and monitor special projects including data analysis and provider claim settlements as requested. 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. Assist with the development of the Provider Policy and Procedure Manual as requested. 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. Manage and Facilitate Administrative Decisions for claims reimbursement exceptions by analyzing reports, documenting request, and preparing data for Director and Chief approvals. Any other duties as required ensuring Health Plan operations are successful.
Qualifications:
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
Bachelors 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 Drivers 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!
Work Model Location:
This position is on a hybrid work schedule. (Mon & Fri remote, Tues Thurs onsite in Rancho Cucamonga, CA)
Pay Range: USD $30.72 USD $39.94 /Hr.
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