Medical Operations Specialist

Southern California United Food & Commercial Workers Unions & Food Employers Joint Benefit Funds Administration, LLC (The Funds) were created more than 40 years ago as a result of collective bargaining between the Southern California Retail Food Employers and the Southern California UFCW Union Locals. The Funds serve in excess of 100,000 participants! There are two Funds, the Pension Fund and the Benefit Fund--through which member retirement and health and welfare benefits are provided.

The Funds Office is currently searching for a supportive Medical Operations Specialist, to join our growing Healthcare Claims Team. In this role, you will be responsible for the operational efficiency and accuracy of medical claims processed by providing support to the staff and supervisor. This position is subject to Collective Bargaining.

Key Responsibilities:

Oversee and manage all operations within the Medical Claims department to ensure efficient processing and resolution of claims.

• Develop and implement policies and procedures to improve the quality and efficiency of claims processing.
• Collaborate with cross-functional teams to streamline processes and enhance overall member satisfaction.
• Train, mentor, and lead the claims team to achieve departmental goals and support professional development.
• Monitor departmental performance metrics and prepare reports for senior management to inform strategic decision-making.
• Professionally and effectively communicate with plan participants, Local Union representatives and employer representatives, in person, on the telephone, email, or US mail.
• Handle and resolve complex issues that require further escalation
• Perform excellent customer service and assist participants with issues they may have.

Qualifications:

• High School diploma or GED required
• Associates degree or a combination of education and experience preferred
• 4-6 years prior experience in medical customer service and claims
• PPO claims processing experience, including prior experience in WGS processing system preferred
• Knowledge of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS), Medical Terminology
• Knowledge with International Classification of Diseases (ICD) ICD-9/ICD-10 codes and guidelines
• Ability to manage multiple projects with various deadlines strongly desired
• Able to utilize MS Office (Excel, Word and Outlook) proficiency required
• Excellent customer service skills with the ability to build rapport with Plan participants, team members and other employees of the Fund

The Funds is an equal employment opportunity employer and no candidate for employment will be rejected on the basis of race, color, religion, national origin, age, marital status, or sex. Candidates with physical impairments or limitations will be considered to the extent it can be reasonably demonstrated that the duties and responsibilities can be effectively performed without endangering the individual, colleagues or surroundings.

The Funds offers exceptional benefit packages that includes a 401(K) plan, pension plan, vacation, holiday, education reimbursement and much more!

Internal Position: Medical Claims Department Head