CCSB Eligibility Specialist I

PINNACLE CLAIMS MANAGEMENT INC; Irvine (CA); On-site; USD 42,000 - 54,000; Full time

Job summary

PINNACLE CLAIMS MANAGEMENT INC is seeking an Eligibility Specialist I to support Child Care Providers United (CCPU) enrollment and billing on the CCPU Portal and HCPS. You will deliver high-quality customer service, educate providers on eligibility processes, and resolve reimbursement issues.

The role requires a high school diploma and 1–3 years of accounting or business experience, strong Word/Excel/Outlook skills, HIPAA and ERISA knowledge, and fluent Spanish.

Qualifications

• High school diploma or equivalent required.
• 1–3 years accounting or business experience preferred.
• Strong proficiency in Word, Excel, and Outlook.
• Spanish language fluency required.

Responsibilities

• Maintain eligibility for CCPU accounts and HCPS.
• Process enrollment transactions (adds/changes/terminations) per guidelines.
• Produce electronic spreadsheets/reports for audits.
• Explain reimbursement issues to providers.
• Ensure HIPAA compliance and protect confidential data.
• Meet processing cycle time standards and due dates.
• Create and document at least one SOP annually.
• Identify process improvements and annual innovations.
• Provide excellent customer service to providers.

Skills

Customer service

Spanish language

Communication

Analytical abilities

Multitasking

Attention to detail

Independent work

Education

High school diploma or equivalent

Tools

Word

Excel

Outlook

Job description

JOB DESCRIPTION SUMMARYUnder 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 RESPONSIBILITIESDepartment OperationsMaintain 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 ServiceSupport 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.OtherUtilize 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/WORKENVIRONMENTThe 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.QUALIFICATIONSHigh 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.