Claims Representative Senior - Remote in CA & NV

About the position Responsibilities • Perform complex and extensive research, analysis, and logical conclusions of paper and electronic claims to resolve disputes. • Conduct necessary follow-up with internal departments to validate payment integrity related to regulatory agencies, contracts, policy, coding, and system configuration. • Act as a department resource and support Customer Service in resolving Practice Connect issues. • Respond to provider calls related to disputes and appeals for incoming provider/member disputes. • Identify, trend, and report the Provider Dispute and Resolution process for management, preparing reports summarizing observations and recommendations for quality improvement. • Provide qualified data to the Business Operations Compliance & Regulatory Manager for training programs and policies. • Confer with management to assess training needs in response to identified trends. • Collaborate with other departments and management to implement and reinforce policy quality standards. • Maintain regular and consistent attendance. Requirements • High School Diploma or GED required. • Must be 18 years of age or older. • Claims adjudication experience is required. • Knowledge of different lines of business including Commercial, Medi-Cal, Medicare, and medical procedure codes. • 3+ years related experience with intermediate to advanced knowledge of claims processing, compliance, and regulatory governing agencies (CMS, DMHC, DHS). • 4+ years of medical claims knowledge is required. • Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. • Knowledge of healthcare regulations and guidelines including CMS, DHCS, and DMHC as pertains to AB1455. • Ability to work any shift between the hours of 8:00 AM - 5:00 PM PST from Monday - Friday. Benefits • Comprehensive benefits package • Incentive and recognition programs • Equity stock purchase • 401k contribution