CCSB Eligibility Specialist III

Pinnacle Health Solutions; Irvine (CA); On-site; USD 85,000 - 120,000; Full time

Job summary

Pinnacle Health Solutions is seeking an experienced CCSB Eligibility Specialist III to lead training, manage complex eligibility and billing for CCSB accounts, and provide escalation support. The role focuses on maintaining compliance, handling escalations, and driving process improvements within a healthcare benefits environment.

The ideal candidate has 5–7 years in accounting/finance, strong analytical abilities, and expert knowledge of HIPAA and ERISA regulations.

Qualifications

• BA/BS degree in accounting, finance, or field.
• Five to seven years of accounting/business experience preferred.
• HIPAA, COBRA, California-COBRA, MEWA, ERISA knowledge required.
• Strong analytical and problem-solving skills.
• Excellent written and verbal communication abilities.

Responsibilities

• Mentor and train team members on processes and policies.
• Maintain eligibility and billing for CCSB accounts.
• Assist in escalations and complex case handling.
• Produce reports and monitor SLAs and performance.
• Collaborate with leadership and stakeholders to resolve issues.

Skills

Team leadership

Analytical thinking

Customer service

Training & coaching

Communication skills

Education

BA/BS in accounting or finance

Tools

Microsoft Office Suite

Eligibility software systems

Case management tools

Job description

JOB DESCRIPTION SUMMARYThis position reports to the Supervisor I, Enrollment and Eligibility. The Covered CA Small Business (CCSB) Eligibility Specialist III will be responsible for performing the most complex work and specialized assignments in determining eligibility for employee benefit plans within the CCSB exchange. This includes working on exceptions, researching escalated requests as well as performing all activities that the CCSB Eligibility Specialists I and II perform. This role involves providing escalated direction and training to less experienced staff, managing complex cases, and ensuring compliance with regulations and policies.DUTIES AND RESPONSIBILITIESTeam DevelopmentAssist in training and mentoring new/existing team members, ensuring they understand and integrate key concepts and practices.Provide ongoing support and guidance to new/existing team members, fostering a culture of continuous learning and development.Collaborate with new/existing team members to identify their strengths and areas for improvement, tailoring training approaches accordingly.Encourage a supportive and inclusive environment, promoting teamwork and mutual respect.Use data to monitor and evaluate the progress of new team members, providing constructive feedback and recognizing achievements.Department OperationsMaintain Eligibility and Billing for CCSB accounts as assigned including clients that submit eligibility electronically.Provide support to CCSB call center team based on business needs, ensuring efficient and effective customer service operations.Review manual and/or (adds, changes, terminations) in the system of record as received from the client or internal sources in accordance with Participation Agreements, Employer Policy Statements, Eligibility Guidelines, and/or Summary Plan Descriptions.Collaborate with CCSB Leadership and Third-Party administrators to resolve any escalated issues.Foster and maintain a strong business relationship with the group contact, ensuring smooth communication and addressing any escalations or issues that may arise, including the management of EDI files, manual adjustments, and billing concerns for the special handle account.Produce electronic spreadsheets and/or reports for daily reporting purposes.Provide timely and effective customer service to clients for requests, inquiries or issues concerning enrollment and/or billing items on their account.Perform full reconciliations on accounts in order to confirm that the group is in compliance.Meet processing cycle time standards and production due dates as set forth by management.Interface effectively with internal departments and external vendors, brokers, or other business contacts to coordinate interrelated activities and resolve eligibility and/or billing issues as they arise.Become the subject matter expert for troubleshooting issues and escalations. Act as point of contact for client escalations.Process Improvement & Cost ContainmentDevelop procedural strategies and operations processing including department policies and guidelines.Collaborate with cross-functional teams to drive continuous process improvement initiatives, supporting broader organizational goals.Initiate and follow up on reporting to ensure SLAs are met.Research and resolve Carrier discrepanciesAssist in the process for all Standard Operating Procedures (SOP) to be updated according to changes made in the process throughout the year.Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.Identify, initiate, and implement at least one process improvement and/or innovation annually.Monitor and communicate to management processes deficiencies and recommended solutions.Monitor business needs and develop documented processes and procedures as needed to create and maintain effective and productive workflows.OtherMaintain integrity and transparency in all tasks, ensuring alignment with team and organizational goals.Hold oneself accountable by taking ownership of actions, decisions, and their outcomes.Reflect on personal performance regularly, identifying areas for improvement and celebrating successes.Commit to continuous learning and growth, seeking feedback and implementing constructive changes.Serve as a representative of CCSB displaying professionalism, knowledge, customer service and discretion in all interactions with other members of the CCSB community and their customers.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/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.QUALIFICATIONSBA/BS degree in accounting, finance, or field and/or five (5) to seven (7) years of Accounting/Business experience preferred.Detail-oriented with advanced skills in establishing priorities, multi-tasking, time management, and ability to work independently with minimal supervision in a team environment.Expert knowledge of generally accepted Health Care Eligibility and Billing procedures as well as Health Insurance Portability and Accountability Act (HIPAA), Consolidated Omnibus Budget Reconciliation Act (COBRA), California-COBRA, Multiple Employer Welfare Arrangement (MEWA) and Employee Retirement Income Security Act (ERISA) legislation.Strong knowledge of audit procedures to be able to assist audit team when needed.Advanced computer experience with Microsoft Office SuiteStrong analytical and problem-solving skills.Proficiency in eligibility software systems and case management tools preferred.Advanced experience providing customer service to a variety of client contacts via email and telephone.Strong ability to research and resolve technical issues and/or client problems as they arise with minimal direction.Ability to provide training and lead a team.Excellent written and oral communication skills including modern business communications formatting of professional letters, reports, and phone etiquette.Advanced knowledge of health insurance operations and industry.Fluent in Spanish, both verbal and written a plus.Ability to work overtime based on department needs and compliance.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.