Description
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 (TPA) 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. We are also a proud contracted partner with Covered California. 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:$39,208 - $55,975 with a rich benefits package that includes profit-sharing.
Job Description Summary
Under the direction of the Director, Operations, the Bilingual Child Care Providers United (CCPU) Eligibility Specialist II will perform enrollment and billing functions necessary to Child Care Providers United accounts on the CCPU Portal and Healthcare Common Procedure Coding System (HCPS) as assigned including groups that submit Electronic Data Interchange (EDI) eligibility. The incumbent will provide customer service support to providers by instructing them on correct eligibility management and explaining billing reimbursement issues. In addition, this person will research and resolve eligibility and billing reimbursement 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.
• Excellent oral and written communication skills in English and Spanish, to include modern business communications, formatting of professional letters, reports, and phone etiquette, required.
• Comprehensive command of the Spanish language with the ability to utilize it up to 50% of the time.
• Knowledge of generally accepted health care eligibility and billing procedures as well as Health Insurance Portability and Accountability Act (HIPAA), and Employee Retirement Income Security Act (ERISA) legislation.
• Intermediate computer experience with Microsoft Office suite.
• 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.
• Demonstrated time management skills including, multi-tasking, working under pressure and deadlines, and working independently with minimal supervision or in a team environment.
• Strong knowledge of health insurance operations and industry.
• 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

• Maintain eligibility and benefit application for CCPU accounts as assigned including providers that submit eligibility electronically.
• Review and process all manual and EDI enrollment transactions (adds, changes, terminations) received from the CCPU, providers, or internal sources in the Administration Portal and HCPS according to Participation Agreements, Employer Policies, Eligibility Guidelines, and Summary Plan Descriptions.
• Produce electronic spreadsheets and reports for audit and processing purposes.
• Research and correct benefit application issues in CCPU Portal and HCPS. Determine and correct out of-balance items on accounts. Contact clients to explain and resolve billing reimbursement discrepancies. Verify/authorize refunds for terminations and/or overpayments.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.
• Meet processing cycle time standards and production due dates as set forth by management on a consistent basis.
• Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and 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 providers to facilitate payments on time and for the correct reimbursement amount.
• Provide timely and effective customer service to clients for requests, inquiries, or issues concerning enrollment and reimbursement items on their accounts.
• Interface effectively with internal departments and external vendors, brokers, or other business contacts to coordinate interrelated activities and resolve eligibility and billing issues as they arise.
• Serve as a representative of CCPU displaying professionalism, knowledge, customer service, and discretion in all interactions.

Other

• 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.
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