Claims Specialist - Claims Processing at Providence Health Care, Inc

Anaheim, California, United States -

Full Time

Start Date

Immediate

Expiry Date

06 Aug, 26

Salary

33.73

Posted On

08 May, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Medical Claims Processing, HMO Claims, Benefit Determination, Reinsurance Qualification, Claims Adjustment, Managed Care, Provider Relations, Customer Service, Conflict Resolution, Policy Compliance

Industry

Hospitals and Health Care

Description

Responsible for processing medical claims. Resolves complex, difficult or non-routine claims requiring special handling in accordance with established policy guidelines. Reviews and authorizes payment and final disposition of claims requiring adjustment and claims benefit determination for reinsurance qualification. Handles complex, difficult or non-routine incoming and outgoing telephone inquiries regarding claims status, benefit quotations, benefit determination and denial information. Interacts with IPAs, Medical Groups, Providers, Hospitals and Members. Responds to written inquiries received from the above-named groups. Providence caregivers are not simply valued – they’re invaluable. Join our team at Providence Medical Foundation and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. Required Qualifications: * HMO claims processing experience in a managed care environment, preferably PMG/IPA setting within the last 3 years or any combination of education and/or experience which produces an equivalency. Why Join Providence? Our best-in-class benefits [https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Fprovidence.jobs%2Fbenefits%2F&data=05%7C01%7Cethelleah.torres1%40providence.org%7C6da11282629946c936bc08dbf64b1e78%7C2e3190869a2646a3865f615bed576786%7C0%7C0%7C638374574718197112%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=CHUc7JRL0t6AAExYx6UfCEVEH8gfmaw9cEOZ4wX0%2BZU%3D&reserved=0] are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security. We take care of you, so you can focus on delivering our Mission [https://providence.jobs/mission/] of caring for everyone, especially the most vulnerable in our communities. At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits [https://providence.jobs/benefits/]. Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act [https://s3-us-west-2.amazonaws.com/images.provhealth.org/HR-onboarding/LA_County_Fair_Chance_Ordinance_2024.pdf]. Providence Clinical Network (PCN) is a service line within Providence serving patients across seven states with quality, compassionate, coordinated care. Collectively, our medical groups and affiliate practices are the third largest group in the country with over 11,000 providers, 900 clinics and 30,000 caregivers. PCN is comprised of Providence Medical Group in Alaska, Washington, Montana and Oregon; Swedish Medical Group in Washington’s greater Puget Sound area, Pacific Medical Centers in western Washington; Kadlec in southeast Washington; Providence’s St. John’s Medical Foundation in Southern California; Providence Medical Institute in Southern California; Providence Facey Medical Foundation in Southern California; Providence Medical Foundation in Northern and Southern California; and Covenant Medical Group and Covenant Health Partners in west Texas and eastern New Mexico. Providence is proud to be an Equal Opportunity Employer [https://www.providenceiscalling.jobs/eeo/]. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity [https://providence.jobs/diversity/] makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.

Responsibilities

Responsible for processing complex medical claims and authorizing payments in accordance with policy guidelines. Handles difficult inquiries from providers, hospitals, and members regarding benefit determinations and claim status.