Claims Resolution Specialist
About the role
The Team You'll Join
We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.
Responsibilities
Responds to provider questions and researches issues regarding claims payments, denials, resolves claim issues, contractual and/or CalOptima Health agreements, established payment methodologies, division of financial responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures.
Follows up with providers as needed.
Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
Affords assistance to the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
Ensures accurate and timely documentation regarding all issues, and/or inquiries are entered in Facets.
Routes escalated calls to the appropriate departments and/or management.
Requirements
High school diploma or equivalent PLUS 2 years of experience in claims resolution 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.
1 year of call center experience with high call volumes or customer service experience required.
1 year of HMO, Medi-Cal/Medicaid and healthcare/managed care experience required.
Qualifications
Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
Work independently and exercise sound judgment.
Communicate clearly and concisely, both orally and in writing.
Work a flexible schedule; available to participate in evening and weekend events.
Organize, be analytical, problem-solve and possess project management skills.
Manage multiple projects and identify opportunities for internal and external collaboration.
Motivate and lead multi-program teams and external committees/coalitions.
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.
Benefits
Competitive compensation for this role.
CalPERS pension program and additional retirement packages.
A comprehensive benefits package including a generous PTO program, a quality work life balance, various wellness programs, tuition reimbursement, professional development opportunities, career development opportunities, flexible scheduling, and the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.
Pay
Pay Grade: 304 - $53,813 - $80,720 ($25.87 - $38.8077).
Schedule
The position is approved for Full Telework (**If the position is Telework, it is eligible in California only**).
Training will be held in the office for the first 2 weeks, Monday - Friday from 8:00am - 4:30pm. A comprehensive benefits package.