Claims Resolution Specialist
Claims Resolution Specialist
Posted on :
13-04-2025
Employer Active
1 Vacancy
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Job Description
The Claims Resolution Specialist provides assistance inresolving provider claims payment status issues provider payment disputes eligibility and authorization verification. The incumbent will be responsible for following regulatory requirements in conjunction with policies and procedures as they apply to the Customer Service department.
Position Responsibilities
- Addresses provider inquiries questions and concerns in all areas including enrollment claims submission and payment benefit interpretation and referrals/authorizations for medical care.
- Verifies member eligibility claims and authorization status for providers.
- Responsible for thorough followup and completion of all providers inquires or requests.
- Outreaches to Health Network(s) providers and collection agencies when appropriate to resolve claims billing claims payment and provider payment disputes.
- Assists providers with CalOptima Web Portal registration and technical support.
- Functions efficiently and productively in a highvolume call center while maintaining departmental productivity and quality standards.
- Follows up with providers as needed.
- Responsible for accurate complete and correct documentation into Facets regarding all issues inquiries complaints and grievances.
- Routes escalated calls to the appropriate departments and/or supervisor.
- Adheres to company and departmental policies and procedures.
Requirements
Possesses the Ability To:
- Meet and maintain established quality and production standards.
- Work independently and as part of a team.
- Develop and maintain effective working relationships with all levels of staff and providers.
- Handle multiple tasks and meet deadlines.
- Maintain a professional demeanor in a highpace environment.
- Learn procedures and regulations governing member eligibility and the terminology and documents used while remaining knowledgeable ofCalOptima/MediCal and Medicare benefits and procedures.
- Utilize computer and appropriate software (e.g. Microsoft Office: Word Outlook Excel PowerPoint) and job specific applications/systems to produce correspondence charts spreadsheets and/or other information applicable to the position assignment.
Experience & Education
- High School graduate or equivalent required.
- 1 year call center experience with high call volumes or customer service experience analyzing and solving provider claims problems required.
- 2 years of claims experience required.
Preferred Qualifications:
- Health Maintenance Organization (HMO) Medicare MediCal / Medicaid and Health Services experience preferred.
Knowledge of:
- Principles and practices of managed health care health care systems and medical terminology.
- Principles and techniques for handling provider customer service issues.
- Revenue Codes Current Procedural Terminology (CPT) 4 / Healthcare Common Procedure Coding System (HCPCS) International Classification of Disease (ICD)10.
- Health Care Finance Administration (HCFA) (CMS1500 and Uniform Billing (UB04 claim forms.
- Industry pricing methodologies such as ResourceBased Relative Value Scale (RBRVS) Medicare / MediCal fee schedule AllPatient Diagnosis Related Groups (APDRG) Ambulatory Payment Classifications (APC)
- Principles and practices of managed health care health care systems and medical terminology.
- Benefit interpretation and administration.
- Principles and techniques for handling customer service issues.
- Customer service principles and practices.
Benefits
Job Type: Fulltime
Salary: $24.52 $31.04 per hour
Expected hours: 40.00 per week
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
- Weekends as needed
Ability to commute/relocate:
- Orange CA 92868: Reliably commute or planning to relocate before starting work (Required)
Experience:
- Medicare: 1 year (Preferred)
- claims: 2 years (Required)
- Medical coding: 1 year (Preferred)
- call center solving provider claims: 1 year (Required)
Required Experience:
Unclear Seniority
Employment Type
Full-Time
Department / Functional Area
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