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Claims Research Specialist
Company : Catholic Health Initiatives
Location : Bakersfield, CA, 93301
Job Type : Full Time
Salary : 30.91-45.98 HOUR
Date Posted : 31 December 2025
Job Summary and Responsibilities
The Claims Research Specialist will oversee and manage research efforts related to claims overpayments, underpayments, and billing issues within a managed care service organization. This role involves review/ensuring accurate and timely resolution of discrepancies, and working collaboratively with providers and internal departments to enhance claims processes and improve financial outcomes.
Essential Functions:
- To research, and identify root cause resulting in claim processing discrepancies for all claim types
- Perform an analysis of the claims processing by reviewing contract, system configuration, benefits, financial risk (DOFRs), and manual adjudication to identify the cause of the erroneous claim payment
- Responsible to ask clarifying questions from our internal supporting departments or external providers when information is incomplete or inaccurate to ensure thorough and accurate research
- Responsible for communicating via inquiry form, email and telecommunication across multiple areas of the organization to ensure customer resolution is complete
- Lead investigations into claims overpayments, underpayments, and billing issues, ensuring accurate identification and resolution of discrepancies.
- Analyze complex claims data to identify trends, root causes, and opportunities for process improvement.
- Ensure thorough documentation of all research activities and findings, maintaining accurate records for audit purposes.
- Collaborate with internal departments, including claims processing, UM, compliance, and provider relations, to develop and implement strategies to prevent future claims issues.
- Participate in the development and enhancement of claims processing systems and tools.
- Recommend policy and procedure changes based on research findings to improve efficiency and accuracy in claims processing.
- Serve as the primary point of contact for the providers and/or provider relations team regarding claims research issues, facilitating effective communication and resolution of disputes.
- Educate providers on claims submission guidelines and billing practices to reduce the occurrence of errors.
- Build and maintain strong working relationships with provider representatives.
- Prepare and present detailed reports on claims research activities, findings, and outcomes to senior management.
- Ensure compliance with all relevant federal, state, and local regulations, as well as organizational policies and procedures.
- Monitor and respond to regulatory changes that impact claims processing and research activities.
- Schedule and lead meetings with all affected areas to provide status updates of next steps, expected completion dates, and resolution of the issues
- Maintain and monitor a comprehensive dashboard of the current open and resolved claim issues
Job Requirements
Minimum Qualifications:
- Bachelors degree in Business, Healthcare Administration, or a related field or experience in lieu of.
- Minimum of 5 years of experience in claims research, analysis, or a related role within a managed care or healthcare environment
- Proven experience in a lead role, with strong project team management skills.
- Advanced knowledge of healthcare claims processing, coding (ICD-10, CPT, HCPCS), and billing practices.
- Proficiency in using a managed care and/or claims processing platform.
Preferred Qualifications:
- Experience with data analytics tools and software such as SQL, SAS
- Previous experience working directly with healthcare providers or within a provider network setting
- Masters in Business, Healthcare Administration, or related field
Where You'll WorkThe purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.
Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options, including medical, dental and vision plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.
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Frequently asked questions
Bakersfield’s healthcare sector is growing, but claims research roles remain moderately competitive due to specialized skills needed. Candidates with advanced knowledge in ICD-10 coding and managed care platforms typically stand out, as local providers seek experts who can enhance claims accuracy and reduce payment errors.
In Bakersfield, certifications like Certified Professional Coder (CPC) or Certified Claims Professional can boost your profile. Employers also value familiarity with California’s healthcare regulations and managed care systems, which helps in navigating state-specific billing nuances efficiently.
Successful specialists are adept at dissecting complex claims data, pinpointing root causes of payment errors, and communicating clearly with providers. Expertise in claims coding systems like ICD-10, CPT, and hands-on experience with claims platforms distinguish top performers in this field.
Progression often moves from analyst roles into leadership or claims management, with opportunities to oversee teams and influence policy changes. Specialists who master data analytics and cross-department collaboration can transition into strategic positions improving claims operations.
Daily tasks require resolving discrepancies in claims, engaging multiple departments, and ensuring compliance with evolving regulations. Specialists must be problem solvers, managing investigation timelines while educating providers on billing to prevent recurring errors.
At Catholic Health Initiatives, Claims Research Specialists play a critical role by enhancing financial outcomes and supporting patient-centered care. Their work ensures claims accuracy aligns with organizational goals, fostering collaboration between providers and internal teams.
This role offers a unique blend of leadership in claims analysis combined with a strong emphasis on provider education and regulatory compliance, all within a values-driven organization focused on quality care and comprehensive managed service support.
In Bakersfield, Claims Research Specialists typically earn between $65,000 and $85,000 annually, depending on experience and certifications. Specialized knowledge in healthcare claims coding and managed care platforms can push salaries toward the higher end of this spectrum.
While many claims specialist jobs in Bakersfield require on-site presence due to collaborative needs, some employers offer partial remote work options. However, roles involving direct provider interaction and system coordination often favor in-person availability.
Proficiency with managed care claims platforms, SQL for data queries, and analytics tools like SAS is highly valued locally. Familiarity with electronic health records and billing systems tailored to California providers further enhances job effectiveness.