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Claims Resolution Specialist

Date Posted: 6/5/2024

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Job Description

Claims Resolution Specialist (Customer Service)

Orange, CA (On-Site)

Schedule: 8am-5pm

Salary: - $24/Hour

The Claims Resolution Specialist will be the first line of contact for Health providers. The incumbent will assist providers with questions related to the payment of claims and resolution of claims payment issues.

Duties & Responsibilities:

80% - Claims Support

Responds and researches issues on provider questions regarding claims payments, denials, resolves claim issues, contractual and/or 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% - Completes other duties or projects as assigned.

Minimum Qualifications:

High School diploma or equivalent required.

2 years of experience in claims resolution required.

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.

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.

Preferred Qualifications:

Required Licensure / Certifications

Knowledge & Abilities:

Develop rapport and establish and maintain effective working relationships with 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

Physical Requirements (With or Without Accommodations):

Ability to visually read information from computer screens, forms and other printed materials and information.

Ability to speak (enunciate) clearly in conversation and general communication.

Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.

Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting

Lifting and moving objects, patients and/or equipment 10 to 25 pounds

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability
To apply please email your resume to

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Job Snapshot

  • Employee Type:Full-Time
  • Location:Orange, CA
  • Job Type:Customer Service
  • Experience:None
  • Education:None
  • Date Posted:6/5/2024
  • Contact: Melissa Canlas (949) 617-3094
  • Pay Range: $24.00 - $24.00 Hourly
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Job Reference: JN -062024-368778