Claims Specialist I – Provider Claims

IEHP

. Evaluate professional, high dollar, and outpatient/inpatient institutional claims .

Posted 10/9/2026full-timeRemote • California • United StatesMid-LevelSenior💰 $26 - $33 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in evaluating and processing institutional and professional medical claims, with a strong understanding of ICD-10, CPT coding, and regulatory requirements. Proven ability to handle provider disputes, appeals, and adjustments while maintaining high standards of customer service and communication.

Highest-signal resume keywords

Medical Claims System ProficiencyICD-10 and CPT CodingProvider Dispute ResolutionManaged Care ExperienceAnalytical and Problem-Solving Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProcessingICD-10 CodingCPT CodingHCPC CodingData AnalysisRegulatory InterpretationMedical Benefit Coverage DeterminationProvider Contract Rate InterpretationAdjustment Request ProcessingTyping 45 WPM

Soft Skills

Excellent Communication SkillsInterpersonal SkillsOrganizational SkillsProblem-Solving SkillsProfessional Demeanor

Tools & Technologies

Microsoft OfficeAdvanced Microsoft Excel

Certifications & Qualifications

High School Diploma or GED

Industry Keywords

HMOManaged CareMedicareMedi-CalClaims Industry StandardsHEDISCAHPSNCQA Accreditation

About the role

Key responsibilities & impact

Evaluate professional, high dollar, and outpatient/inpatient institutional claims
Determine coverage and payment levels
Evaluate and resolve provider disputes and appeals
Issue resolution letters
Process adjustment requests timely and accurately in accordance with standard procedures and regulatory guidelines
Participate in payment adjustment projects
Handle complex claims as assigned
Incorporate IEHP’s 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 the following areas: Medical claims system, ICD-10 and CPT coding
Reviewing medical authorizations
Provider contract rate interpretation, medical benefit coverage determination
Prior experience handling provider disputes, appeals and claim adjustments
Experience preferably in and 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
A thorough understanding of claims industry and customer service standards
Knowledge of ICD-9, ICD10, CPT, HCPC coding and general practices of claims processing
Strong analytical and problem-solving skills
Microsoft Office, Advanced Microsoft Excel
Written communication skills
Ability to analyze data and interpret regulatory requirements
Excellent communication and interpersonal skills, strong organizational skills, and skilled in data entry required
Typing a minimum of 45 wpm
Excellent oral and written communication skills
Ability to build successful relationships across the organization
Professional demeanor
Telephone courtesy and high degree of patience

Benefits

Comp & perks

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