Claims Resolution Specialist - Alliance Solutions

Job Title: Claims Resolution Specialist (Immediate Need)

Claims Resolution Specialist  Pay Range: $24.52 - $31.04

Claims Resolution Specialist  Schedule: 8:30am-5:30pm, Monday-Friday

Claims Resolution Specialist  Start Date: ASAP

We are seeking a Claims Resolution Specialist for a 6 month contract opportunity for the single largest health insurer in Orange County, providing coverage.The Claims Resolution Specialist will provide 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 policies and procedures as they apply to the Customer Service department. 

Claims Resolution Key Responsibilities: 

• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.

• 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.

• Ensures thorough follow-up and completion of all provider inquiries 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  Health 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.

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

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

• Adheres to company and departmental policies and procedures.

Claims Resolution  Skills and Experience:  

• High School diploma or equivalent required.

• 2 years of claims experience required.

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

• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying. 
   

• Principles and practices of managed health care, health care systems and medical terminology.

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

If you believe you are a qualified candidate for our Claims Resolution Specialist  , please click apply below to apply on our website!