Claims & Customer Service Rep (Medical Benefits)

Medical Claims and Customer Service Position

Mostly Remote

This is a Hybrid position, and it will be rare that you have to work onsite. Most of it is remote work, but you still have to live in the Los Angeles CA area to be considered.

This role is customer-facing and is considered a key customer service representative for the Health Organization. The Medical Claims Specialist/Analyst will process health insurance claims and answers calls from the customer (participant members, providers, physicians, hospitals etc.) Adhere to eligibility, claims and call policies and procedures while making sound claim/call decisions. Create relationships through the resolution of customer incoming call requests. Serve our customers by determining requirements, answering inquiries, resolving problems, and fulfilling requests.

Responsibilities:

• Answer incoming phone calls from customers and identify the type of assistance the customer needs (e.g. benefit and eligibility, billing and payment inquiries, authorizations for treatment and explanation of benefits (EOBs))
• Communicate and collaborate with customers to resolve issues, using clear, simple language to ensure understanding
• Review and research incoming healthcare claims by navigating multiple computer systems and platforms and verify the data/information necessary for processing (e.g. pricing, prior authorizations, and applicable benefits)
• Ensure that the proper health benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, grievance procedures, federal mandates, CMS/Medicare guidelines, and benefit plan documents/certificates)
• Conducts research and analysis of historical, current and future benefit trends, service improvements and impacts to fund

Qualifications and Education Requirements:

• Bachelor's Degree in Healthcare, Math, Engineering or related field required
• Minimum of four (3) years of claims processing preferred
• Minimum of four (2) years in heavy call center required
• Learn various software applications and become self-sufficient in using the software in a user interface environment
• Demonstrate adaptability and forward-thinking in the face of technological or organizational change
• Proficient with Microsoft products, including Word, Excel and Outlook
• Excellent customer service and telephone skills
• Knowledge of medical terminology
• Ability to research and verify claims payment, benefits, and eligibility issues
• Strong knowledge of benefits plans, policies and procedures

Company Benefits:

• Salary range offered $56,000-$63,000 to start
• Medical, Dental & Vision Health Insurance is paid 100% by Employer (you can add up to 5 dependents for health coverage, and it costs $50 a month total for dependents coverage).
• 401K with 2% Employer Match
• Employer Pension! Vested after 5 years
• PTO- 2 weeks 5 weeks of time off depending on your years with the company
• Holiday Pay -2 Floating Holidays & you get your Work Anniversary off every year
• Sick Pay 12 days a year
• Career advancement opportunities & the ability to work for a very reputable and longstanding organization.

Equal Opportunity Employer