Claims Resolution Specialist (Customer Service)

CalOptima is a mission-driven community-based organization that serves member health with excellence and dignity. The Claims Resolution Specialist (Customer Service) will assist providers with questions related to claims payments and resolution of claims payment issues, playing a key role in the Claims Administration team.

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

Requirements:

• 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