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CalOptima · 12 hours ago

Claims Resolution Specialist (Customer Service)

Orange, CA

Full-time

Onsite

Entry, Mid 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 payment and resolution of issues, contributing to a stronger, more equitable health system.

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 resolutionCall center experienceHMO/Medi-Cal/Medicaid experienceCustomer serviceMicrosoft OfficeProblem-solvingCommunication skillsProject management

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