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 will start as a six month in-office temporary position with the possibility of going permanent (and remote) for the right candidate. A permanent job does include excellent government benefits and a pay raise.

Pay range: $25-$32/hr depending on experience.

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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