About the Position

The Claims Resolution Specialist will be responsible to provide assistance in resolving provider claims payment status issues, provider payment disputes, eligibility and authorization verification. The position will be responsible for following regulatory requirements in conjunction with Company's policies and procedures as they apply to the Customer Service department.

Duties & 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. Ensures 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 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. Provides accurate, complete and correct documentation 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. Completes other duties or projects as assigned.

Experience & Education:

High School diploma or equivalent required. 2 years of claims experience required. 1 year of call center experience with high call volumes or customer service experience analyzing and solving provider claims problems required. An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications:

Experience in a Health Maintenance Organization (HMO), Medicare, Medi-Cal/Medicaid and Health Care environment.

Health Insurance Dental Insurance Vision Insurance 401K Paid Time Off Life Insurance

Job Type: Full-time

Pay: $20.00 - $22.00 per hour

Benefits: 401(k) Dental insurance Health insurance Life insurance Paid time off Vision insurance Schedule: Day shift

Experience: Microsoft Office: 1 year (Preferred) Customer service: 1 year (Preferred)

Work Location: In person