Claims Administration Specialist

Duties & Responsibilities

• Affords support to the team in executing departmental responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Maintains adequate information in company systems and ensures data collection, summarization, integration and reporting, which includes case creation and management and events/activity tracking.
• Gathers pertinent information regarding the grievances and appeals received, including member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal or supplemental information required to evaluate grievances and appeals within regulatory requirements.
• Coordinates and participates in case discussions with operational experts to result in a final case disposition as needed.
• Evaluates case details, proposes recommendations or makes decisions as applicable and ensures the organization's decision is implemented according to the Grievance and Appeals policies and case resolution.
• Develops resolution letters and correspondence to members and providers.
• Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals.
• Contacts appropriate parties to request and obtain missing information and supporting documentation or provides education.
• Reads and interprets provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions.
• Responds to routine provider inquiries via phone, assisting with provider appeals resolution inquiries.
• Affords assistance with the health networks' compliance process.
• Identifies trends and root causes of issues, proposes solutions or escalates ongoing issues to management.
• Maintains performance measurement goals for Grievance and Appeals Resolution Services.

Minimum Qualifications

• A high school diploma or equivalent.
• One year of experience with Provider Dispute Resolution in Medicare and Medi-Cal in professional, institutional, outpatient, ancillary, coordination of benefits and government cases.
• One year of experience with Medicare or Medi-Cal provider appeals and denials process.
• One year of experience in any of the following areas: Grievances and Appeals, Claims Administration, Regulatory Compliance, Customer Service or related field.

Preferred Qualifications

• An associate degree in business, health care administration or related field.
• Experience in health care practice standards, for both government and commercial plans.
• Bilingual in English and in one of company defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).

Pay

Hourly pay: $26- $38.00 per hour.

Schedule

On-site position. Work Schedule: Monday-Friday 8am- 5pm.

Benefits

JSG offers medical, dental, vision, life insurance options, short-term disability, 401(k), weekly pay, and more.

About the Role

Johnson Service Group (JSG) is seeking a Bilingual Claims Resolution Specialist in Orange, CA. This is an on-site position.

Qualifications

This is a full-time position.

Skills

High school diploma or equivalent PLUS 1 year of experience with Provider Dispute Resolution in Medicare and Medi-Cal in professional, institutional, outpatient, ancillary, coordination of benefits and government cases required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

Requirements

Associate degree in business, health care administration or related field.

Benefits

JSG offers medical, dental, vision, life insurance options, short-term disability, 401(k), weekly pay, and more.

Johnson Service Group (JSG)

Johnson Service Group (JSG) is an Equal Opportunity Employer. JSG provides equal employment opportunities to all applicants and employees without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, marital status, protected veteran status, or any other characteristic protected by law. #D800