Claims Phone Representative

4 days ago

Orange, United States Astiva Health, Inc Full time

Job Title: Claims Phone Representative

Target Compensation Range: $22.00 - $23.00/hour, depending on the relevant qualifications and experience.


About Us:

Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.


SUMMARY:

Under the direction of the Claims Vice President. This position is responsible for answering phone inquiries from providers/callers regarding claim status, appeal status, check tracers, and other related concerns regarding professional, facility, and/or dental claims for both the Health Plan and the MSO.


ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

  • Handle inbound and outbound phone calls, emails, and other necessary communications with providers/callers.
  • Provide exceptional customer service as needed for claims resolution.
  • Attempt to resolve the provider/caller’s issue completely during the first phone call.
  • Provide accurate and complete information using the tools provided. Ability to identify the correct received date, paid date, paid amount, denial/adjustments, etc. and/or any other information related to claim/appeal status.
  • Review and interpret the Division of Financial Responsibility (DOFR) for claims processing to misdirect inquiries to delegated IPAs/MSOs as needed.
  • Able to explain member benefits and verify member eligibility to benefit plan, and answer questions and concerns as needed.
  • Maintains good working knowledge of system/internet and online tools used to process claims.
  • Maintain updated knowledge of all time frames for meeting compliance for all lines of business.
  • Coordinate with Claim Examiners, Adjustors, Auditors, and the VP of claims on issues related to the submission or processing of claims, appeals, medical records, checks, refunds, etc. determined to be the financial responsibility of the Health Plan or MSO.
  • Regular and consistent attendance.
  • Other duties as assigned.


EDUCATION and/or EXPERIENCE:

  • High School Diploma or GED required
  • 2+ years of customer service experience. Call center experience preferred.
  • 2+ years’ experience with Medicare Advantage, Health Plan, IPA, or medical group.
  • Demonstrated proficiency in MS Office (Excel, Word, Outlook, and PowerPoint).
  • Able to navigate difficult situations with empathy, discretion, and professionalism. Excellent verbal and written communication skills including active listening and probing techniques.
  • Ability to multi-task, time manage, and prioritize.
  • Able to live our mission, vision, and values.
  • Good knowledge of CPT/HCPCS/ICD-10, and Revenue Codes, including modifiers and adjustment codes.
  • Bilingual in a second language preferred (Spanish or Vietnamese, written and verbal).


BENEFITS:

  • 401(k)
  • Dental Insurance
  • Health Insurance
  • Life Insurance
  • Vision Insurance
  • Paid Time Off

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