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CalOptima · 17 hours ago

Claims Resolution Specialist (Customer Service)

Orange, CA

Full-time

Onsite

Entry Level

$54K/yr - $81K/yr

2+ years exp

CalOptima is a mission-driven community-based organization that serves member health with excellence and dignity. They are seeking a Claims Resolution Specialist (Customer Service) to assist providers with questions related to claims payments and resolution of claims payment issues, while being an integral part of the Claims Administration team.

GovernmentHealth CareNon Profit

Comp. & Benefits

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

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

Qualification

Claims resolution experienceCustomer service experienceHMO/Medi-Cal/Medicaid experienceCall center experienceMicrosoft Office proficiencyAnalytical skillsCommunication skillsProblem-solving skillsProject management skillsTeam collaboration

Required

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