Medical Claims Resolution Specialist

Job Duties

Adds 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 follow-up and completion of all provider inquiries or requests.

Outreaches to Health Network(s), providers, and collection agencies when appropriate to resolve claims billing, claims payment, and provider payment disputes.

Aids providers with Agency Web Portal registration and technical support.

Functions efficiently and productively in a high-volume 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.

Requirements

• High School graduate or equivalent required (will be verified)
• 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.
• Health Maintenance Organization (HMO), Medicare, Medi-Cal / Medicaid, and Health Services experience preferred.
• Knowledge of Revenue Codes, Current Procedural Terminology (CPT) -4 / Healthcare Common Procedure Coding System (HCPCS), International Classification of Disease (ICD)-10.
• Knowledge of Health Care Finance Administration (HCFA) (CMS-1500) and Uniform Billing (UB-04) claim forms.

Pay

Pays between $25/hr - $31/hr depending on experience.

Schedule

Temporary position (in-office, onsite) for 6 months.

Benefits

Full-time permanent position includes a pay raise, telecommute options, a CalPERS Pension, and excellent government benefits including generous holiday, PTO and sick pay days off, year one!