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Claims Resolution Specialist

Company: The Judge Group
Location: Orange
Posted on: June 5, 2024

Job Description:

Judge Healthcare is currently seeking Claims Resolution Specialist in Orange, CA!!Contract:6 monthsHours:Monday-Friday, business hoursLocation:On-site (Orange, CA)Claims Resolution SpecialistAs a Claims Resolution Specialist, you will play a crucial role in managing and resolving insurance claims efficiently and accurately. Your responsibilities will include reviewing and adjusting claims, conducting research, and communicating with claimants and insured individuals while maintaining privacy and adhering to HIPAA laws. Additionally, you?ll negotiate settlement agreements, coordinate with providers, and identify trends associated with incorrect payments.Key Responsibilities:Claims Management:Review and analyze insurance claims for assigned territories or individual accounts.Guide claims from initial report to completion, ensuring timely resolution.Follow up on unpaid claims and manage their resolution throughout all phases, including evaluation, litigation, and negotiation.Communication and Collaboration:Address provider inquiries, questions, and concerns related to enrollment, claims submission, payment, benefit interpretation, and referrals/authorizations for medical care.Verify member eligibility, claims, and authorization status for providers.Ensure thorough follow-up and completion of provider inquiries or requests.Collaborate with Health Network(s), providers, and collection agencies to resolve claims billing, claims payment, and provider payment disputes.Assist providers with CalOptima Health Web Portal registration and technical support.Efficient Operations:Work efficiently and productively in a high-volume call center environment.Maintain departmental productivity and quality standards.Follow up with providers as needed.Document all issues, inquiries, complaints, and grievances accurately in the Facets system.Escalate calls to appropriate departments or supervisors when necessary.Skills and Qualifications:Meet and maintain established quality and production standards.Work both independently and as part of a team.Handle multiple tasks and meet deadlines.Maintain a professional demeanor in a fast-paced environment.Stay current on procedures and regulations governing member eligibility, terminology, and relevant documents.Establish and maintain effective working relationships with CalOptima Health?s leadership and staff.Communicate clearly and concisely, both orally and in writing.Utilize computer software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems for producing correspondence, charts, and spreadsheets.Experience and Education: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 is also qualifying.Preferred Qualifications:Experience in a Health Maintenance Organization (HMO), Medicare, Medi-Cal/Medicaid, or the health care environment.For immediate consideration email your resume to Brittany Kirking at Jobble

Keywords: The Judge Group, Orange , Claims Resolution Specialist, Other , Orange, California

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