Medical Claims Resolution Specialist

Kinetic Personnel Group is currently recruiting for a Claims Resolution Specialist for a Public Health Agency (government entity). This position will be based in Orange County. This 3 billion-dollar a year government public agency is renowned for its work in the community and being a great place to work.

The Claims Resolution Specialist provides 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 Agency’s policies and procedures as they apply to the Customer Service department.

This position is a 6 month temporary position (in-office, onsite) that pays between $25/hr - $31/hr depending on experience. This will become a permanent position for the right candidate.

A full time permanent position includes a pay raise, telecommute options, a CalPERS Pension and excellent government benefits including generous holiday, PTO and sick pay days off, year one!

Job duties:

• 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.

• Responsible for thorough follow-up and completion of all providers inquires 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 Agency Web 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.

• Responsible for accurate, complete, and correct documentation into Facets regarding all issues, inquiries, complaints, and grievances.

• Routes escalated calls to the appropriate departments and/or supervisor.

Requirements:

• High School graduate or equivalent required (will be verified)

• 1+ year call center experience with high call volumes or customer service experience analyzing and solving provider claims problems required.

• 2+ years of claims experience required.

• Health Maintenance Organization (HMO), Medicare, Medi-Cal / Medicaid, and Health Services experience preferred.

• Revenue Codes, Current Procedural Terminology (CPT) -4 / Healthcare Common Procedure Coding System (HCPCS), International Classification of Disease (ICD)-10.

• Health Care Finance Administration (HCFA) (CMS-1500) and Uniform Billing (UB-04) claim forms.

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