CLAIMS SERVICE SPECIALIST River City Medical Group 14 reviews - Sacramento, CA Who We Are River City Medical Group (RCMG) is a progressive Independent Physician Association (IPA) of over 700 physicians uniquely dedicated to serving over 170,000 members within Sacramentos Medi-Cal population. Founded by longtime community physicians in 1992, it is our mission to not only understand the needs of our diverse communities, but to address them with creative and culturally sensitive health care solutions. RCMG serves as a supportive link between health plans, providers, and the members with a dedication to ensuring our entire health care delivery process operates smoother. With over 230 dedicated employees and growing, RCMG is an active member of the community helping to support it in our professional roles as an IPA. With the robust leadership of local practicing physicians, we are committed to ensuring our members and physicians are supported to provide the right care at the right time. * A dedicated team implementing creative solutions to assist providers with focusing more on patient care and less on administration * Community relations developing public and private partnerships that improve access to care and link members to services * Doctors providing care to almost 1 in 2 Medi-Cal Beneficiaries in the Sacramento area * Only IPA based in Sacramento County exclusively dedicated to serving the Medi-Cal population It is the policy of RCMG to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, RCMG will provide reasonable accommodations for qualified individuals with disabilities. Job Summary Responsible for customer service calls from providers in assisting callers as it relates to the claims adjudication. Acts as the first impression person representing RCMG to callers. Provide claim status and assistance as directed by Supervisor. Research and respond to eligibility claim issues. Responsibilities * Provides a full range of assistance to providers via telephone or correspondence concerning claims. * Answers telephone in a prompt, professional, courteous and helpful manner; responds to questions regarding claims status and eligibility inquiries. * Responsible for maintaining and logging accurate phone calls in the Customer Service Module within the Portal and forwarding any potential adjustments via call ticket to the appropriate unit. * Demonstrates a comprehensive knowledge of Health Plan Benefits and the various departmental functions. * Analyzes and identifies concerns/issues and refers to appropriate department if deemed necessary. * Evaluates and processes claims and claim adjustments in accordance with company policies and procedures according to productivity and quality standards. * Interprets and processes routine to moderate claims inquiries. * Checks for erroneous items or codes and missing information and corrects errors according to established procedures. * Maintains current knowledge of RCMG members' benefits, policies/procedures, provider network development and contract issues, processing system issues, Medi-Cal regulations, as well as industry standards for claims adjudication. * Researches, updates and/or adds eligibility to previously entered claims. * Consistently maintains production standards based on transactions/units per hour. * Consistently meets quality standards. * Performs other related duties consistent with the scope and intent of the position. * Regular attendance. Educational/License Requirements * High School diploma or equivalent required. * Associate degree preferred. Qualifications and Experience * One (1) year experience in a Customer Service Call Center required. * Claims experience in managed care claims processing preferred. * Familiarity with ICD-9/10, HCPCS, CPT coding, modifiers, DMHC regulations, facility and professional claim billing practices. * Ability to maintain production level and quality goals. * Ability to demonstrate self-motivation, multi-task, exercise excellent time management, follow through on commitments and meet multiple deadlines. * Work product demonstrates excellent attention to detail, is accurate, thorough and effective. * Excellent communication skills, including both oral and written. * Excellent active listening and critical thinking skills. * Ability to solve entry to mid-level problems with supervision.