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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in evaluating and processing institutional and professional medical claims, with proficiency in ICD-10 and CPT coding. Strong analytical skills and the ability to communicate effectively with providers while ensuring compliance with HIPAA and quality program goals.
Highest-signal resume keywords
Medical Claims EvaluationICD-10 And CPT CodingProvider Dispute ResolutionAnalytical And Problem-Solving SkillsMicrosoft Excel Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Claims SystemsICD-10 CodingCPT CodingClaims Processing PracticesData AnalysisRegulatory Requirements InterpretationTyping Speed Of At Least 45 WPMProvider Contract Rate InterpretationMedical Benefit Coverage DeterminationClaims Adjustment
Soft Skills
Written Communication SkillsInterpersonal SkillsOrganizational SkillsTelephone CourtesyProfessional Demeanor
Tools & Technologies
Microsoft OfficeProvider Dispute Database
Certifications & Qualifications
High School DiplomaGED
Industry Keywords
HMOManaged CareMedicareMedi-CalClaims Industry StandardsHEDISCAHPSNCQA Accreditation
About the role
Key responsibilities & impact- Evaluate professional, high-dollar, and outpatient/inpatient institutional claims to determine coverage and payment levels
- Review and process provider dispute resolutions according to state and federal designated timeframes
- Research reported issues, adjust claims, and determine dispute root causes
- Draft professional written responses to providers within required timelines
- Independently review and price complex edits across all claim types to determine appropriate payment or denial handling
- Complete the required weekly reviews
- Respond to provider inquiries regarding submitted disputes
- Maintain, track, and prioritize assigned caseload in IEHP’s provider dispute database
- Maintain claims procedure knowledge and participate in ongoing training
- Research cases and gather information through verbal and written communication
- Recommend process improvements based on trending and analysis of incoming provider disputes
- Coordinate with departments to resolve claim-related issues
- Identify and report billing issues for provider education
- Perform other duties required for successful Health Plan operations
- Ensure privacy and security of PHI in accordance with IEHP policies and HIPAA compliance
- Incorporate IEHP Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation
Requirements
What you’ll need- Minimum of four (4) years of experience evaluating and processing institutional and professional medical claims
- Proficiency in medical claims systems, ICD-10 and CPT coding
- Experience reviewing medical authorizations
- Provider contract rate interpretation and medical benefit coverage determination
- Prior experience handling provider disputes, appeals and claim adjustments
- Experience preferably in an HMO or Managed Care setting
- Medicare and/or Medi-Cal experience preferred
- Experience in a managed care or government payer environment helpful
- High School Diploma or GED required
- Thorough understanding of claims industry and customer service standards
- Knowledge of ICD-9, ICD-10, CPT, HCPC coding and general claims processing practices
- Strong analytical and problem-solving skills
- Microsoft Office and advanced Microsoft Excel proficiency
- Written communication skills
- Ability to analyze data and interpret regulatory requirements
- Excellent communication and interpersonal skills
- Strong organizational skills and data entry skills
- Typing speed of at least 45 wpm
- Ability to build successful relationships across the organization
- Professional demeanor
- Telephone courtesy and a high degree of patience
Benefits
Comp & perks- Competitive salary
- State of the art fitness center on-site
- Medical Insurance with Dental and Vision
- Life, short-term, and long-term disability options
- Career advancement opportunities and professional development
- Wellness programs that promote a healthy work-life balance
- Flexible Spending Account – Health Care/Childcare
- CalPERS retirement
- 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance