DaVita Claims Specialist II in EL SEGUNDO, California

Claims Specialist II


DaVitaMedical Group manages and operates medical groups and affiliated physiciannetworks in California, Nevada, New Mexico, Florida, Colorado and Washington inits pursuit to deliver excellent-quality health care in a dignified andcompassionate manner. As of June 30, 2016 DaVita Medical Group (formerlyHealthCare Partners) provided integrated care management for approximately760,000 patients. DaVita Medical Group’s leadership development initiatives andsocial responsibility efforts have been recognized by Fortune, ModernHealthcare, Newsweek and WorldBlu.

Weare committed to bringing the benefits of coordinated care to our patients andto taking a leading role in the transformation of the national healthcaredelivery system to assure quality, access, and affordable care for all.

Ifyou're looking to make a difference with a large, financially stable,well-recognized medical group, DaVita Medical Group may be the employer foryou.


Responsiblefor processing allprofessional medical claims, appeals, and prepayment audits for payment, denialor referral for the appropriate payor. Answersincoming telephone inquiries and accurately and thoroughly documents problemsand resolutions. Troubleshoots claims that have been identified as needingadditional work in the areas of eligibility, referral, authorization,contracting, and/or provider set-up.

Essential Functions:

  • Consistently exhibits behavior and communicationskills that demonstrate HealthCare Partners’ (HCP) commitment to superiorcustomer service, including quality, care and concern with each and everyinternal and external customer.

  • Processes all types of professional claims andadjusts professional disputed claims according to department, contract, andregulatory requirements.

  • Performs prepayment audit on all types of professionalclaims according to department, contract, and regulatory requirements.

  • Processes simple facility claims as neededaccording to department, contract, and regulatory requirements.

  • Answers telephone inquiries through the “AutomatedCall Distributor (ACD) Telephone System” as needed.

  • Identifies individual provider needs and takeappropriate steps to satisfy those needs.

  • Updates authorization information based oninformation obtained from facilities.

  • Analyzes work processes and identifies areasneeding improvements.

  • Participates in the continuous quality improvementof IMCS core business system.

  • Follows unit procedures for performing callprocessing, claim adjustments and denials and references Policies andProcedures, job aides, provider contracts, and other reference materials toassure complete and accurate decisions.

  • Uses, protects, and discloses HCP patients’protected health information (PHI) only in accordance with Health InsurancePortability and Accountability Act (HIPAA) standards.

  • Performs additional duties as assigned.



  • High school diploma, G.E.D. or equivalent. Includes special certification required forspecific jobs.



  • Over 3 years and up to and including 5 years ofexperience in an indemnity and/or HMO setting processing, auditing or adjustingprofessional claims.


  • Computer literate.

  • Knowledge of Microsoft Office products.

  • Individual must be reliable, dependable, andpunctual.

  • Excellent customer service and telephone skills.

  • Excellent verbal and written communication skills.

  • Ability to work in an environment with fluctuatingworkloads.

  • Ability to solve problems systematically, usingsound business judgment.

  • Ability to make decisions with every call andhandle escalated issues.

  • Ability to make decisions regarding escalation ofreferrals to Care Management.

  • Familiarity with ICD-9 and CPT codes.

  • Knowledge of all types of professional claims

  • Ability to research and verify claims paymentissues.

  • Knowledge of compliance related to the processingof claims.

  • Knowledge of medical terminology and pricingoptions.

  • Knowledge of different sources of authorizationdocumentation.

  • Ability to read and interpret all vendor contracts.

DaVita Medical Group is an equal opportunity/affirmative action employer. As such, DaVita Medical Group makes hiring decisions solely on the basis of qualifications and experience, and without regard to age, race, color, religion, sex, gender identity, sexual orientation, national origin, disability or protected veteran status.

We maintain a drug-free workplace and perform pre-employment substance abuse testing and background verification checks.

DaVita Medical Group will consider qualified applicants who have criminal histories in a manner consistent with the law.

Primary Location CA-EL SEGUNDO - 90245

Req ID: 309005