California Licensed Claims Specialist

Job Summary

A company is looking for a Claims Specialist I - Provider Claims.

Key Responsibilities

• Evaluate professional and institutional claims to determine coverage and payment levels
• Resolve provider disputes and appeals, issuing resolution letters and processing adjustment requests
• Manage payment adjustment projects and complex claims as assigned

Required Qualifications, Training, and Education

• Minimum of four years of experience in evaluating and processing medical claims
• Proficiency in medical claims systems, ICD-10, CPT coding, and provider contract rate interpretation
• Experience handling provider disputes, appeals, and claim adjustments, preferably in HMO or Managed Care settings
• High School Diploma or GED required
• Medicare and/or Medi-Cal experience preferred