CCSB Eligibility Specialist I

Pinnacle Health Solutions; Irvine (CA); On-site; USD 28,000 - 39,000; Full time

Job summary

Pinnacle Health Solutions is seeking an Eligibility Specialist I to manage enrollment and billing tasks for CCPU accounts in the CCPU Portal and HCPS. You will assist providers with eligibility management and explain reimbursement issues while delivering exceptional customer service.

You will handle enrollment transactions, generate reports, and maintain HIPAA-compliant data practices, aiming to meet processing deadlines and identify process improvements across operations.

Qualifications

• High school diploma or equivalent with 1–3 years accounting/business experience.
• HIPAA and ERISA knowledge related to healthcare eligibility and billing.
• Proficient with Word, Excel, and Outlook and able to learn a proprietary health care system.
• Customer service experience with email and phone communications.
• Ability to research and resolve issues with minimal direction.
• Strong written and oral communication skills.
• Ability to prioritize, multi-task, and work independently or in a team.
• General knowledge of health insurance operations.
• Spanish language ability (read, write, speak) required.

Responsibilities

• Maintain eligibility for CCPU accounts including electronic submissions.
• Process enrollment transactions in HCPS per guidelines and data from various sources.
• Produce electronic spreadsheets and reports for audits and processing.
• Research and correct enrollment issues; explain reimbursements to clients.
• Maintain HIPAA-compliant workstation and protect data confidentiality.
• Meet processing cycle times and production deadlines set by management.
• Identify inefficiencies and propose improvements to save time and reduce risk.
• Create and document at least one SOP annually.
• Initiate and implement at least one process improvement annually.

Education

High school diploma or equivalent with 1–3 years accounting/business experience

Job description

Job Description Summary

Under the direction of the Director, Operations, the Child Care Providers United (CCPU) Eligibility Specialist I is responsible for performing enrollment and billing functions necessary to maintain Child Care Providers United accounts on the CCPU Portal and Healthcare Common Procedure Coding System (HCPS) as assigned. The role is also responsible for providing the highest level of customer service support to providers by instructing them on correct eligibility management and explaining reimbursement issues.

Under the direction of the Director, Operations, the Child Care Providers United (CCPU) Eligibility Specialist I is responsible for performing enrollment and billing functions necessary to maintain Child Care Providers United accounts on the CCPU Portal and Healthcare Common Procedure Coding System (HCPS) as assigned. The role is also responsible for providing the highest level of customer service support to providers by instructing them on correct eligibility management and explaining reimbursement issues.

Duties And Responsibilities

Department Operations

• Maintain eligibility for CCPU accounts as assigned including clients that submit eligibility electronically.
• Assist in reviewing and processing all manual and/or Electronic Data Interchange (EDI) enrollment transactions (adds, changes, terminations) in HCPS as received from CCPU, providers, or internal sources in accordance with Participation Agreements, Employer Policy Statements, Eligibility Guidelines and Summary Plan Descriptions.
• Assist in producing electronic spreadsheets and reports for audit and processing purposes.
• Research and correct account application issues in CCPU Portal and HCPS. Determine and correct benefit parameters on accounts. Contact clients to explain and resolve billing reimbursement discrepancies. Verify and authorize refunds for terminations and 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.
• 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

• Support providers by facilitating qualifications 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 with other members of the CCPU community and their customers.

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/WORKENVIRONMENT

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.

Qualifications

• High school diploma or equivalent and one (1) to three (3) 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) and Employee Retirement Income Security Act (ERISA) legislation.
• Strong computer aptitude with Word, Excel, and Outlook and the ability to develop a strong proficiency working with a proprietary Health Care system.
• Experience providing Customer Service to a variety of client contacts via email and telephone.
• Ability to research and resolve technical issues or client problems as they arise with minimal direction.
• Proficient written and oral communication skills including modern business communications, formatting of professional letters, reports, and phone etiquette.
• Ability to establish priorities, multi-task, work under pressure and deadlines, and work independently with minimal supervision or in a team environment.
• General knowledge of health insurance operations and industry.
• Ability to speak, read, and write in Spanish, required.
• 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.