California Licensed Claims Specialist

Job Summary

Evaluating and resolving provider claims, the full-time California Licensed Claims Specialist will assess professional and institutional claims, manage disputes and appeals, and process adjustments in a remote environment.

Key responsibilities

• Evaluate high dollar and outpatient/inpatient institutional claims to determine coverage and payment levels
• Resolve provider disputes and appeals, issuing resolution letters and processing adjustment requests accurately and timely
• Participate in payment adjustment projects and manage complex claims as assigned

Required qualifications

• Minimum of four years of experience in evaluating and processing institutional and professional medical claims
• Proficiency in ICD-10 and CPT coding, as well as medical claims systems
• Experience handling provider disputes, appeals, and claim adjustments
• High School Diploma or GED required; experience in a managed care or government payer environment preferred
• Knowledge of medical benefit coverage determination and provider contract rate interpretation