Claims Resolution Specialist (Customer Service)

About the role

We are a mission-driven, community-based organization serving member health with excellence and dignity. As a Claims Resolution Specialist (Customer Service), you will be an integral part of our Claims Administration team, collaborating with providers, community partners, and local stakeholders to ensure members receive equitable, respectful healthcare.

This position is approved for full telework; if approved, you must work within the State of California. If partial telework is approved, you are required to come into the Main Office in Orange, CA, at least two days per week.

Responsibilities

• Claims Support (80%)
  • Respond to provider questions and research issues related to claims payments, denials, and resolution.
  • Interpret contractual and CalOptima Health agreements, payment methodologies, division of financial responsibility, applicable regulatory legislation, claims processing guidelines, and company policies and procedures.
  • Follow up with providers as needed.
• Administrative Support (15%)
  • Participate in a mission-driven culture emphasizing high-quality performance, member-focused customer service, consistency, dignity, and accountability.
  • Assist the team in carrying out department responsibilities and collaborate to support short- and long-term goals and priorities.
  • Ensure accurate and timely documentation of all issues and inquiries in Facets.
  • Route escalated calls to the appropriate departments or management.
• Other duties or projects (5%)
  • Complete other duties or projects as assigned.

Requirements

• High school diploma or equivalent PLUS 2 years of experience in claims resolution required.
• An equivalent combination of education and experience sufficient to perform the essential duties 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.

Knowledge & Abilities

• Develop rapport and maintain effective working relationships with leadership, 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, analyze, problem-solve, and possess project management skills.
• Work in a fast-paced environment efficiently.
• 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 other applicable information.

Physical Requirements

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

Benefits

• Competitive compensation within the hiring range: Pay Grade 304 — $53,813 to $80,720 ($25.87 to $38.8077 hourly). Final salary based on education, job-related knowledge and experience, relevant skills, and internal equity.
• Full telework eligibility (must work within California if telework is approved).
• Comprehensive benefits package including CalPERS pension and additional retirement options.
• Generous PTO program and quality work-life balance.
• Various wellness programs, tuition reimbursement, and professional/career development opportunities.
• Flexible scheduling.

Work Environment

• If located at 500, 505 Building or remote:
  • Indoors, sedentary role subject to schedule changes and variable hours; travel as needed.
  • No harmful environmental conditions; moderate noise level.
• If located at PACE:
  • Indoors in a clinical setting serving the frail and elderly.
  • Possible harmful or hazardous environmental conditions; moderate to loud noise level.
• If located in the community:
  • Indoors and sedentary, subject to schedule changes and variable hours; travel as needed.
  • Occasional outdoor work in varied temperatures.
  • Possible harmful or hazardous environmental conditions; moderate to loud noise level.