Out-of-State Provider Specialist - Remote California

Summary

As an Out-of-State Provider Specialist – Remote California at Gainwell, you will support California's Medi-Cal program by reviewing out-of-state healthcare claims, coordinating provider enrollment activities, and ensuring accurate processing in accordance with established program requirements. You'll work with healthcare providers, internal teams, and the California Department of Health Care Services (DHCS) to resolve issues, maintain accurate documentation, and support efficient claims and enrollment operations.

Your role in our mission

• Review, research, and correct out-of-state (OOS) healthcare claims in accordance with Medi-Cal policies, procedures, and processing requirements.

• Process enrollment activities for out-of-state medical and outpatient providers, reviewing documentation for accuracy and completeness.

• Evaluate provider eligibility against established OOS criteria and refer providers who do not meet applicable requirements to DHCS for enrollment processing.

• Coordinate billing and enrollment materials, respond to provider inquiries, research discrepancies, and maintain accurate records and activity logs.

• Track daily and weekly activities, prepare required reports, and meet established productivity, quality, and contractual requirements.

What we're looking for

• High school diploma or GED required; an associate or bachelor's degree in healthcare administration, business, or a related field is a plus.

• Experience in healthcare claims processing, provider enrollment, medical billing, Medicaid/Medi-Cal operations, or healthcare administrative support preferred.

• Knowledge of healthcare claims, provider enrollment procedures, medical billing terminology, or insurance reimbursement processes preferred.

• Strong analytical, problem-solving, organizational, and time-management skills with the ability to research discrepancies and maintain accurate records.

• Excellent communication and computer skills, including proficiency with Microsoft Office applications and the ability to work independently in a remote environment.

What you should expect in this role

• 100% remote position. Applicants must reside in California.

• Full-time position supporting California's Medi-Cal program.

• Ability to work independently while collaborating with internal teams and healthcare providers.

• Reliable high-speed internet access and a private, professional workspace are required.

This is a pipeline requisition to identify qualified candidates for anticipated future openings as business needs arise.

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