Claims Resolution Specialist (Customer Service)

CalOptima is a mission-driven community-based organization that serves member health with excellence and dignity. They are seeking a Claims Resolution Specialist (Customer Service) to assist providers with claims payment questions and issues, while contributing to a collaborative team environment.

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