Lead Claims Specialist – Claims Processing

Providence

. Manage claims internal audit functions, including audits of adjudicated claims and encounters .

Posted 10/16/2026full-timeRemote • California • United StatesSenior💰 $28 - $43 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing claims audits, ensuring compliance with health plans and regulations, and developing training programs for claims processing. Proven ability to maintain provider satisfaction while adapting to policy changes and enhancing operational efficiency.

Highest-signal resume keywords

Claims Processing ExperienceClaims Audit ManagementCompliance with State and Federal RegulationsProvider Dispute Resolution KnowledgeClaims Training Program Development

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AuditingClaims ProcessingPolicy DevelopmentCompliance MonitoringTraining Program DesignClaims AdjudicationLegislation FamiliarityTimeliness ComplianceQuality AssuranceCustomer Satisfaction Management

Soft Skills

CommunicationLiaison SkillsProblem-SolvingAdaptabilityTeam Collaboration

Industry Keywords

Health PlansClaims ComplianceProvider-Vendor RelationsState and Federal LegislationClaims Denial Timeliness

About the role

Key responsibilities & impact

Manage claims internal audit functions, including audits of adjudicated claims and encounters
Monitor the check run process for accuracy
Develop policies and procedures for periodic claims audits
Ensure compliance with affiliated health plans, client groups, and administrative contractual agreements
Design, plan, direct, and implement claims training programs
Adapt training programs to changes in policies, procedures, and technologies
Ensure customer (provider-vendor) satisfaction while maintaining integrity
Serve as a liaison between contracted health plans, patients, hospitals, and the Information Technology Department
Provide day-to-day assistance and training on claims compliance matters to Claims Examiners and Adjudication teams
Support customer-measured quality and responsiveness requirements

Requirements

What you’ll need

5 years of professional and facility claims processing experience
Familiarity with applicable State and Federal claim payment and denial timeliness legislation
Familiarity with Timeliness Compliance pursuant to State and Federal rules and regulations
Knowledge of the Provider Dispute Resolution tracking mechanism (AB1455)

Benefits

Comp & perks

Retirement 401(k) Savings Plan with employer matching
Medical, dental, and vision health care benefits
Life insurance
Disability insurance
Paid parental leave
Vacation and holiday time off
Time off for health issues
Voluntary benefits
Well-being resources
Additional compensation may be available through shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities