The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
This position is remote work eligible; Candidates MUST reside in California.
What You Will Be Doing:
Under general supervision, the Claims Resolution Specialist is responsible for effectively addressing and resolving a variety of claims related inquiries and issues from external and internal customers. This role involves researching complex claims escalating by customer service or provider service and ensuring compliance with organizational policies and procedures. The specialist will also reprocess claims when applicable, maintain accurate documentation, and monitor claims related call logs to ensure timely resolutions.
Our Vision:
Continuously improve the health of our community.
Our Mission:
We provide healthcare value and advance wellness through community partnerships.
Essential Functions:
- Respond to and resolve a variety of claim-related inquiries and requests from external and internal customers
- Research and address issues related to claims escalated by customer service or provider service
- Reprocess claims as applicable and create required documentation, including call logs and entries in tracking systems.
- Monitor, address, and escalate claims-related call logs and service request, ensuring necessary actions are taken to resolve issues promptly.
- Collaborate with various departments to facilitate the claims resolution process and improve overall service delivery.
What You Bring:
Knowledge, Skills, Abilities and Competencies
Required
- Ability to understand medical terminology, CPT, ICD-10 coding and HCPCS and their application in claims.
- Ability to understand moderately complex documents, and oral and written communication.
- Ability to work independently and as part of a team in a fast-paced environment.
- Strong analytical and problem-solving skills, including the ability to perform routine analysis and resolve problems using identified data and information.
- In-depth knowledge of regulations governing Medi-Cal, Medicare and/or managed care as they relate to claims.
- In-depth knowledge of general medical policy benefits and exclusions.
- In-depth knowledge of industry standard payment practices.
- In-depth knowledge of claims management systems to access and process claims and adjustments.
- Produce work that is accurate and complete
- Produces the appropriate amount to work
- Time management and organization skills: Uses time effectively and efficiently. Values time, concentrates their efforts on the more important priorities, can attend to a broader range of activities, and meet deadlines.
- Learn quickly when facing new situations, experiments to find new solutions and take on the challenge of unfamiliar tasks and extracts lessons learned from failures and mistakes.
- Rebounds from setbacks and adversity when facing difficult situations.
- Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
- Interpersonal skills – interacts effectively with individuals both inside and outside of the Health Plan; relates openly and comfortably with diverse groups of people.
- Demonstrates a commitment to the Health Plan’s strategy, vision, mission and values.
- Strong oral and written communication skills, with ability to express self clearly and professionally, with appropriate grammar and spelling, and document according to standards.
- Basic to intermediate arithmetic skills
- Basic knowledge of and skills in automated claims processing system
- Microsoft Office Suite.
- Ability to treat confidential information with appropriate discretion
- Ability to speak and be understood in English.
What You Have:
Education and Experience
Required
- High school diploma; and
- One year internal adjustments and disputes, handling moderate call volume, claims, or medical billing coding; and
- Two years of experience in medical claims processing, adjustments, provider relations.
Preferred
- Associate or bachelor’s degree in healthcare administration, business, or related field.
Licenses, Certifications
None.
What You Will Get:
HPSJ Perks:
- Competitive salary
- Robust and affordable health/dental/vision with choices in providers
- Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
- CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
- Two flexible spending accounts (FSAs)
- Employer-Paid Term Life and AD&D Insurance
- Employer-Paid Disability Insurance
- Employer-Paid Life Assistance Program
- Health Advocacy
- Supplemental medical, legal, identity theft protection
- Access to exclusive discount mall
- Education and training reimbursement in addition to employer-paid elective learning courses.
- A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
- A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
- Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.
We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation, and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.
HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics or is associated with anyone who has or is perceived to have these characteristics.
Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.
Equal employment opportunity, including veterans and individuals with disabilities.
