DEPARTMENT(S): Customer Service
REPORTS TO: Manager Customer Service
FLSA STATUS: Non-Exempt
SALARY GRADE: F - $24.52 - $35.43 ($51,000 - $73,700)
JOB SUMMARY
The Claims Resolution Specialist provides assistance in resolving provider claims payment status issues, provider payment disputes, eligibility, and authorization verification. The incumbent will be responsible for following regulatory requirements in conjunction with CalOptima’s policies and procedures as they apply to the Customer Service department.
POSITION RESPONSIBILITIES:
- Addresses 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 providers inquires or requests.
- Outreaches to Health Network(s), providers, and collection agencies when appropriate to resolve claims billing, claims payment, and provider payment disputes.
- Assists providers with CalOptima 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.
- Adheres to company and departmental policies and procedures.
- Other duties or projects as assigned by management.
POSSESSES THE ABILITY TO:
- Meet and maintain established quality and production standards.
- Work independently and as part of a team.
- Develop and maintain effective working relationships with all levels of staff and providers.
- Handle multiple tasks and meet deadlines.
- Maintain a professional demeanor in a high-pace environment.
- Learn procedures and regulations governing member eligibility, and the terminology and documents used while remaining knowledgeable of CalOptima/Medi-Cal and Medicare benefits and procedures.
- Understand and follow oral and written directions.
- Hear and speak well enough to converse on the telephone and in person.
- Communicate clearly and concisely, both verbally and in writing.
- 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.
EXPERIENCE & EDUCATION:
- High School graduate or equivalent required.
- 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.
PREFERRED QUALIFICATIONS:
- Health Maintenance Organization (HMO), Medicare, Medi-Cal / Medicaid, and Health Services experience preferred.
KNOWLEDGE OF:
- Principles and practices of managed health care, health care systems, and medical terminology.
- Principles and techniques for handling provider customer service issues.
- Revenue Codes, Current Procedural Terminology (CPT) -4 / Healthcare Common Procedure Coding System (HCPCS), International Classification of Disease (ICD)-10.
- Health Care Finance Administration (HCFA) (CMS-1500) and Uniform Billing (UB-04) claim forms.
- Industry pricing methodologies, such as Resource-Based Relative Value Scale (RBRVS), Medicare / Medi-Cal fee schedule, All-Patient Diagnosis Related Groups (AP-DRG), Ambulatory Payment Classifications (APC),
- Principles and practices of managed health care, health care systems, and medical terminology.
- Benefit interpretation and administration.
- Principles and techniques for handling customer service issues.
- Understanding of the CalOptima program.
- Customer service principles and practices.
CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
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Required Skills
Required Experience