Claims Resolution Specialist - Covered California

About the Role

This position has been approved for Full Telework within the State of California only. The Claims Resolution Specialist will be the first line of contact for CalOptima Health providers, assisting with questions related to the payment of claims and resolution of claims payment issues.

Responsibilities

• Claims Support (80%): 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.
• Administrative Support (15%): Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists 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.
• Completes other duties or projects as assigned (5%).

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 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.
• Work in a fast-paced environment and in an efficient manner.
• 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.

Physical Requirements

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds.

Pay

• Pay Grade: 304 - $53,813 - $80,720 ($25.87 - $38.8077 per hour). The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.

Benefits

• Comprehensive benefits package
• CalPERS pension program and additional retirement packages
• Generous PTO program
• Quality work life balance
• Various wellness programs
• Tuition Reimbursement
• Professional development opportunities
• Career development opportunities
• Flexible scheduling

Work Environment

• If located at the 500, 505 Building or a remote work location: Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. There are no harmful environmental conditions present for this job. The noise level in this work environment is usually moderate.
• If Located At PACE: Work is typically indoors in a clinical setting serving the frail and elderly. There may be harmful or hazardous environmental conditions present for this job. The noise level in this work environment is usually moderate to loud.
• If Located In The Community: Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. Employee will occasionally work outdoors in varied temperatures. There may be harmful or hazardous environmental conditions present for this job. The noise level in this work environment is usually moderate to loud.