CCSB Eligibility Specialist I

Pinnacle Claims Management; Irvine (CA); On-site; USD 52,000 - 68,000; Full time

Job summary

Pinnacle Claims Management is seeking an Eligibility Specialist I to support Child Care Providers United (CCPU) via the CCPU Portal and HCPS. You will guide providers on eligibility management and explain reimbursement issues while maintaining HIPAA-compliant processes.

The role emphasizes enrollment accuracy, timely processing, and high-quality customer service. Based in Irvine, CA, the position requires attention to detail and strong communication with internal teams and external providers.

Responsibilities

• 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 in HCPS as received from CCPU, providers, or internal sources in accordance with policies.
• 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; contact clients to explain and resolve billing discrepancies; verify refunds for terminations and overpayments.
• Maintain a HIPAA-compliant workstation and utilize security techniques to protect confidential data.
• Meet processing cycle time standards and production due dates set by management.
• Identify inefficiencies within processes and suggest solutions to save time and reduce risk.
• Create and document at least one new SOP annually.
• Identify and implement at least one process improvement annually.
• Support providers by facilitating qualifications on time and for the correct reimbursement amount.
• Provide timely customer service to clients for enrollment and reimbursement inquiries.
• Interface with internal departments and external contacts to coordinate activities and resolve eligibility and billing issues.
• Represent CCPU with professionalism and discretion in all interactions.
• Perform other duties as assigned.

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.