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CCSB Eligibility Specialist II

Company: Western Growers
Location: Irvine
Posted on: May 15, 2022

Job Description:

Join our team of dedicated professionals who are committed to ensuring our clients can provide affordable health benefit solutions for their employees.Part of the Western Growers Family of Companies (WGFC), Pinnacle Claims Management is a 3rd party administrator that provides health benefits administration and related services to companies that self-fund their insurance. We are also a contracted partner with CCSB.Pinnacle is independently owned and has been serving clients for 20+ years. We are also part of the Western Growers Family of Companies.For more details on open positions, visit our !Compensation:$36,304- $52,196 with a rich benefits package that includes profit-sharing.Job Description SummaryPerform Enrollment and Billing Functions necessary to Covered California for Small Business (CCSB) accounts on Healthcare Common Procedure Coding System (HCPS) as assigned including groups that submit Electronic Data Interchange (EDI) eligibility. Provide Customer Service support to clients by instructing them on correct eligibility management and explaining billing/payment issues. Research and resolve eligibility and billing discrepancies or client inquiries.Qualifications

  • High School diploma or equivalent or three (3) to five (5) years of accounting/business experience with knowledge of generally accepted accounting procedures, analytical abilities or equivalent combination of education and 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 computer experience with Microsoft office with intermediate knowledge of Excel spreadsheet manipulation to produce audit files and reports.
  • Strong ability to develop proficiency working with a proprietary health care system.
  • Knowledge of processing Electronic Data Interchange (EDI) file updates in a legacy system.
  • Experience providing customer service to a variety of client contacts via email and telephone.
  • Demonstrated ability to research and resolve technical issues and/or client problems as they arise with minimal direction.
  • Written and oral communication skills including modern business communications, formatting of professional letters, reports and phone etiquette.
  • Demonstrated time management skills including, multi-tasking, working under pressure and deadlines, and working independently with minimal supervision or in team environment.
  • General knowledge of health insurance operations and industry.
  • Bilingual-Spanish verbal/written abilities a plus.Duties And ResponsibilitiesProcess Management & Maintenance
    • Maintain Eligibility and Billing for CCSB accounts as assigned including clients that submit eligibility
    • Review and process all manual and/or EDI enrollment transactions (adds, changes, terminations) in HCPS as received from the client or internal sources in accordance to Participation Agreements, Employer Policy Statement, Eligibility Guidelines and/or Summary Plan
    • Produce electronic spreadsheets and/or reports for audit and processing
    • Research and correct cash application issues in HCPS. Determine/correct out of balance ledger items on accounts. Contact clients to explain and to resolve billing/payment discrepancies. Verify/authorize refunds for terminations and/or
    • Maintain a HIPAA compliant work station and utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee
    • Consistently meet processing cycle time standards and production due dates as set forth by
    • Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.
    • Create and document a minimum of one new Standard Operating Procedure (SOP) annually.
    • Identify, initiate and implement at least one process improvement and/or innovation annually.Customer Service
      • Work with clients to facilitate payments on time and for the billed
      • Provide timely and effective Customer Service to clients for requests, inquiries or issues concerning enrollment and/or billing items on their
      • Interface 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
      • Serve as representative of Western Growers/PCMI displaying professionalism, knowledge, customer service and discretion in all interactions with other members of the Western Growers/PCMI community and their
      • Plan and execute work in a helpful and collaborativeOther
        • 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, being self-accountable, creating a positive impact, and being diligent in delivering results.
        • All other duties asPhysical Demands/Work EnvironmentThe physical demands and work environment described here represent those that an employee must meet to perform this job's essential functions successfully. 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.

Keywords: Western Growers, Irvine , CCSB Eligibility Specialist II, Other , Irvine, California

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