Claims Resolution Specialist (CS) - Sunshine Enterprise USA LLC

Company Overview: Our client is a leading healthcare located in Orange, CA, seeking claims resolution specialist that largely focuses on customer service.

Position Summary: The ideal candidate shall have at least 2 years of experience of Healthcare Claims Resolution experience with 1 year of experience of high-call volume call center.

Position Responsibilities

• Responds and researches issues on provider questions regarding claims payments, denials, resolves claim issues, contractual and/or agreements, established payment methodologies, division of financial responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Ensures accurate and timely documentation regarding all issues, and/or inquiries are entered in Facets.
• Completes other duties or projects as assigned.

Experience & Education

• High School diploma or equivalent required.
• 2 years of claims experience required.
• 1 year of call center experience with high call volumes or customer service experience analyzing and solving provider claims problems required.
• 1 year of HMO, Medi-Cal/Medicaid and healthcare/managed care experience required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Necessary Attributes:

• Develop rapport and establish and maintain effective working relationships with leadership and staff and external contacts at all levels and with diverse backgrounds
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events
• Organize, be analytical, problem-solve and possess project management skills
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment

Please see HR for information on physical demands and work environment of this job.

Sunshine Enterprise USA is an “Equal Opportunity Employer—Minorities, Females, Veterans and Disabled Persons”