Provider Claims Svcs Spec

Job Profile Summary

The Provider Claims Service Specialist is responsible for responding to provider inquiries and resolving issues related to claims processing, reimbursement, and pricing. This role acts as a liaison between providers and internal claims operations teams to ensure accurate, timely resolution and a high level of service in a fast-paced environment.

Key Responsibilities

• Research and resolve provider inquiries related to claim status, pricing, reimbursement, and contract interpretation
• Analyze claim processing issues to identify root causes and implement corrective actions
• Collaborate with internal departments (e.g., Claims, Configuration, Network Management) to address escalated issues
• Review and interpret provider contracts to ensure accurate claims adjudication
• Maintain detailed documentation of issue resolution and provider interactions
• Identify trends and recommend process improvements to enhance operational efficiency and provider experience
• Support provider education by explaining claim outcomes, policies, and procedures

Required Qualifications

• A high school diploma or equivalent required; an Associate’s or Bachelor’s degree preferred
• 2–4 years of healthcare claims processing or provider services experience
• Strong knowledge of medical claims adjudication and reimbursement methodologies
• Familiarity with provider contracts and pricing logic preferred
• Excellent analytical, problem-solving, and communication skills
• Ability to manage high-volume workloads and prioritize effectively
• Proficiency in Microsoft Office (Excel, Word, Outlook) and claims processing systems

About Our Company

Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.

Inclusion and Belonging

At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.