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CLAIMS SPECIALIST - HOAG CLINIC CLAIMS & ENROLLMEN

Department:  Business Services
Status:  Full Time
Shift:  1st

The Claims Specialist (Customer Service) is responsible for answering phone calls from healthcare providers, health plans, billing companies, and members on inquiries related to claims, eligibility, and authorization. The Claims Specialist will ensure first-call-resolution standards are followed and will refer and follow-up as per Hoag Clinic MSO guidelines.

 

Essential Functions

· Assist with resolving telephone calls from customers on inquiries related to claims, eligibility, authorization by accurately identifying customer needs and taking appropriate action

· Follow Hoag Clinic MSO guidelines and policies ensuring compliance with regulatory guidelines and health plan requirements

· Document all incoming calls following HIPAA guidelines in handling patient data

· Assist in identifying and reporting issues working with the Claims management team to help minimize re-work and address front-end process issues

· Interact in a positive and collaborative manner with internal and external partners especially in demanding and tense situations with providers and patients exhibiting a caring, empathetic, and patient attitude

· Support the claims team in implementing initiatives in improving claims processing efficiency

· Assist in provider customer service, member services, health plan, and other customers including making and answering phone calls to providers/billing offices when necessary based on team guidelines

· Perform other duties as assigned

 

Education, Training and Experience Required: High School Diploma or equivalent, 1 year of experience in a medical claims processing or claims customer service in a health plan, medical group, or IPA environment, knowledge of HMO/managed care regulatory guidelines Preferred: Experience with Epic Tapestry CRM system, 2 years of experience in claims adjudication Skills or Other Qualifications Required: Strong moral compass and commitment to Hoag’s values Motivated to learn, continually improve and operate to one’s fullest potential Positive attitude, passionate, excited, strong desire to simplify processes. Experience in providing excellent customer service, empathetic ability Skills to multi-task and manage competing priorities, apply critical thinking to solve problems Tech savvy and posses a capability to quickly learn new applications Ability to maintain composure and compassion while addressing a high volume of competing tasks Comfortable with ambiguity and open to collaborative environments Microsoft Word, Excel, Typing/Data Entry Preferred: Working knowledge of regulatory guidelines in managed care (Title 22, AB1455, AB1203, AB1324, AB72, CMS guidelines, COB guidelines, etc.), claims processing, code categories (CPT, ICD, etc.) License and Certifications Required: Preferred:

 

 

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