Claims Resolution Specialist

Job Description
Claims Resolution Specialist

At Sunshine Enterprise USA, we're not just a company; we're a community of dedicated professionals committed to excellence and innovation. As a leading force in the business landscape, we take pride in bringing together great people and great organizations by fostering a work environment that values creativity, diversity, and growth. If you're ready to embark on a rewarding career journey with a company that prioritizes its employees, explore our current job opportunities below.

Job Title: Claims Resolution Specialist

Department(s): Customer Service

Reports to: Supervisor Customer Service

Hourly: $24.52 - $37.55

Duration: Up to 6 months

Job Summary

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

Position Responsibilities

• 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.
• 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 provider inquiries 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 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 into Facets 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.

Possesses the Ability To:

• Meet and maintain established quality and production standards.
• Work independently and as part of a team.
• Handle multiple tasks and meet deadlines.
• Maintain a professional demeanor in a high-pace environment.
• Learn procedures and regulations governing member eligibility, terminology and documents used while remaining current on Medi-Cal and Medicare benefits and procedures.
• Establish and maintain effective working relationships with leadership and staff.
• Communicate clearly and concisely, both orally and in writing.
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.

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.

Knowledge of:

• Principles and practices of managed health care, health care systems and medical terminology.
• Revenue Codes, Current Procedural Terminology (CPT) -4 / Healthcare Common Procedure Coding System (HCPCS) and International Classification of Disease (ICD)-10.
• Health Care Finance Administration (HCFA) (CMS-1500) and Uniform Billing (UB-04) claim forms.
• Industry pricing methodologies, such as Resource-Based Relative Value Scale (RBRVS), Medicare/Medi-Cal fee schedule, All-Patient Diagnosis Related Groups (AP-DRG), Ambulatory Payment Classifications (APC), etc.
• Benefit interpretation and administration.
• Principles and techniques for customer service, solving customer service issues and provider issues.

At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization, and we are happy to offer the following benefits:

• Competitive pay & weekly paychecks

• Health, dental, vision, and life insurance

• 401(k) savings plan

• Awards and recognition programs

• Benefit eligibility is dependent on employment status.

Sunshine Enterprise USA is an "Equal Opportunity Employer-Minorities, Females, Veterans and Disabled Persons"