DaVita Claims Specialist, Senior in EL SEGUNDO, California

Claims Specialist, Senior


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 September 30,2016 DaVita Medical Group (formerlyHealthCare Partners) provided integrated care management for approximately750,000 patients. DaVita Medical Group’s leadership development initiatives andsocial responsibility efforts have been recognized by Fortune, ModernHealthcare, Newsweek and WorldBlu.

We arecommitted to bringing the benefits of coordinated care to our patients and totaking a leading role in the transformation of the national healthcare deliverysystem to assure quality, access, and affordable care for all.

If you're looking to make a difference with a large,financially stable, well-recognized medical group, DaVita Medical Group may bethe employer for you.


Responsiblefor processing, auditing, and adjusting all professional and facility medicalclaims, appeals and prepayment audits. 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 andcontracting or provider set-up. Trains and assists other analysts with problemclaims and escalated telephone calls.

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 medical claims and adjustsmedical disputed claims (Professional and Facility) according to department,contract, and regulatory requirements.

  • Performs prepayment audit on all types of medicalclaims (Professional and Facility) according to department, contract, andregulatory 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 provider.

  • Troubleshoots problem claims to resolve providerissues or systematic issues.

  • Verifies and interprets information in all vendorcontracts to resolve issues.

  • Trains analysts and monitors general office supportfunctions as needed.

  • Analyzes work processes, identifies areas needingimprovements and initiates necessary steps to make changes.

  • 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 5 years and up to and including 7 years ofexperience in an indemnity and / or HMO setting processing, auditing oradjusting professional claims.


  • Experience in an indemnity and / or HMO settingprocessing, auditing, or adjusting facility 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 update authorization information basedon information obtained from facilities.

  • Ability to read and interpret all vendor contracts.

  • Knowledge of DRG pricing.

Primary Location CA-EL SEGUNDO - 90245

Req ID: 303442