Claims Resolution Specialist

2 weeks ago


Fairfield, California, United States Partnership HealthPlan of California Full time
Job Summary

We are seeking a highly skilled Claims Customer Service Representative I to join our team at Partnership HealthPlan of California. In this role, you will be responsible for researching and resolving provider telephone and written inquiries, accurately screening claims, and participating in provider meetings and projects.

Key Responsibilities
  • Respond to provider inquiries, research policy issues, and analyze EOP's and claim history to recommend and implement resolutions.
  • Communicate outcomes to providers of CIF's, claim tracers, and general claim correspondence within established time frames.
  • Follow established PHC policies and procedures, PHC claims operating instruction memorandums, EDS provider manual guidelines, and Title 22 regulations when resolving claims and claim issues.
  • Participate in provider meetings to resolve claim issues and recognize opportunities for process improvements.
  • Record daily production statistics and related activities on appropriate reports and meet established production and call performance metrics.
  • Participate in special projects and assignments as required and contribute to the resolution of CIFs.
Requirements
  • High school diploma or equivalent; one (1) year of prior claims processing experience in an automated claim environment preferred.
  • Knowledge of CPT, HCPC procedure coding, and ICD-10 diagnostic coding, as well as medical terminology.
  • Excellent written and oral communication skills, with the ability to exercise good judgment and handle sensitive issues with tact and diplomacy.
  • Good organizational skills and ability to accurately complete tasks within established time frames.
Work Environment

Ability to use a computer keyboard and spend more than 80% of work time in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size weighing up to 25 lbs.

All HealthPlan employees are expected to provide the highest possible level of service to clients, promote teamwork and cooperative effort among employees, maintain safe practices, and abide by the HealthPlans policies and procedures.



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