CCSB Eligibility Specialist I

Covered California For Small Business Eligibility Specialist I

If you're looking for a career that provides affordable health benefit solutions to the people who support some of the most vital industries, we're looking for you. At Pinnacle Claims Management, we are an innovative third-party administrator that provides a full-suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees. As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn't a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee's life. One way this is realized for employees of Pinnacle Claims Management is flexible work arrangements with work-from-home, in-office or hybrid options. With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees' job satisfaction and success.

Compensation: $35,288.33 - $45,874.31 with a rich benefits package that includes profit-sharing.

Job Description Summary

This position reports to the Supervisor I, Enrollment and Eligibility. The Covered California for Small Business (CCSB) Eligibility Specialist I will maintain and administer employee benefits within the CCSB Covered CA Small Business exchange. The role involves processing enrollments, terminations, changes, and resolving member inquiries related to the benefit plans.

Qualifications

• High school diploma and/or equivalent and one (1) to three (3) years of Accounting/Business experience preferred.

• Knowledge of generally accepted health care eligibility and billing procedures as well as Health Insurance Portability and Accountability Act (HIPAA), Consolidated Omnibus Budget Reconciliation Act (COBRA), California Continuation Benefits Replacement Act (Cal-COBRA) and Employee Retirement Income Security Act (ERISA) legislation.

• Intermediate experience with Microsoft Office suite. and the ability to develop a strong proficiency working with a proprietary healthcare system.

• Experience providing Customer Service to a variety of client contacts via email and telephone.

• Ability to research and resolve technical issues and/or client problems as they arise with minimal direction.

• Proficient written and oral communication skills including modern business communications, formatting of professional letters, reports, and phone etiquette.

• Skills to establish priorities, multi-task, work under pressure and deadlines, work independently with minimal supervision or in a team environment.

• General knowledge of health insurance operations and industry.

• Fluent in Spanish, both verbal and written a plus.

• Ability to work required overtime based on department needs and compliance.

• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.

• Home router with wired Ethernet (wireless connections and hotspots are not permitted).

• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)

• A functioning smoke detector, fire extinguisher, and first aid kit on site.

Duties and Responsibilities

Department Operations

• Assist in maintaining Eligibility and Billing for CCSB accounts as assigned including clients that submit eligibility electronically.

• Assist in reviewing and processing all manual and/or Electronic Data Interchange (EDI) enrollment transactions (adds, changes, terminations) in the system of record as received from the client or internal sources in accordance with Participation Agreements, Employer Policy Statement, Eligibility Guidelines and/or Summary Plan Descriptions.

• Provide support to CCSB Small Business call center team based on business needs, ensuring efficient and effective customer service operations.

• Meet production and audit metric goals as set forth by management.

• Review audit results and make corrections within the processing cycle time standards and due dates as set forth by management.

• Communicate effectively with internal departments and external vendors, brokers or other business contacts to coordinate interrelated activities and to resolve eligibility and/or billing issues as they arise.

Process Improvement & Cost Containment

• Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.

• Create and document Standard Operating Procedures (SOPs).

• Identify, initiate, and implement at least one process improvement and/or innovation annually.

Other

• Maintain integrity and transparency in all tasks, ensuring alignment with team and organizational goals.

• Hold oneself accountable by taking ownership of actions, decisions, and their outcomes.

• Reflect on personal performance regularly, identifying areas for improvement and celebrating successes.

• Commit to continuous learning and growth, seeking feedback and implementing constructive changes.

• Serve as a representative of CCSB displaying professionalism, knowledge, customer service, and discretion in all interactions with other members of the CCSB community and their customers.

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.

• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.

• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client data.

• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).

• All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here represent those that an employee must meet to successfully perform this job's essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.