Claims Resolution Specialist​/Customer Service Specialist

Job Title: Claims Resolution Specialist / Customer Service Specialist

Duration: 6 months

Location: Orange, CA 92868 Fully Onsite

Payrate: $25.87 to $38.81/hr on W2 without benefits

Shift: Mon - Fri | 8:00 a.m. to 5:00 p.m.

• 80% - Claims Support
• Responds to provider questions and researches issues regarding claims payments, denials, resolves claim issues, contractual and/or Cal Optima 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.
• 15% - Administrative Support
• 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.
• 5% - Other
• Completes other duties or projects as assigned.

• 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.

• Develop rapport and establish and maintain effective working relationships with Cal Optima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.