Bilingual Operations Specialist II
Description
At Pinnacle Claims Management, we are an innovative third-party administrator (TPA) that provides a full-suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees.
As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn’t a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee’s life. One way this is realized for employees of Pinnacle Claims Management is flexible work arrangements with work-from-home, in-office or hybrid options.
With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees’ job satisfaction and success.
Compensation:$ $46,669.19 - $ $60,668.60 with a rich benefits package that includes profit-sharing.
Job Description Summary
This position reports to the Supervisor I, Key Accounts. This position is responsible for serving as the first point of contact for Operations Specialist Is and Field Operations Specialists assigned to their Pod. This position will process financial transactions in the company’s financial processing systems as it relates to individual and group billing, automated clearing house (ACH), and cash receipt processing. The incumbent will also maintain and balance individual accounts receivables including delinquency processing and terminations. Additionally, they will manage all financial aspects of reimbursement requests submitted by consumers, generating desired reports, and processing and approving reimbursement payments via the company’s financial processing systems. The incumbent is responsible for managing all incoming claims and reimbursement requests and processing claims and client reimbursements, including complex claim cases requiring research and resolution. Lastly, they mentor and support the development of the Specialist level I in conjunction with the Team Lead.
Q UA L IF IC A T IO NS
· BA/BS degree in accounting, finance or business-related field preferred plus three (3) to four (4) years experience working in a related field or equivalent combination of education and experience, preferred.
· Excellent oral and written communication skills in English and Spanish, to include modern business communications, formatting of professional letters, reports and phone etiquette, required.
· Comprehensive command of the Spanish language with the ability to utilize it up to 50% of the time.
· Demonstrated ability to multi-task, work in a fast-paced environment, meet established deadlines, and work independently with minimal supervision or in team environment.
· Proficient knowledge of end-user office software i.e., calendaring, word-processing, spreadsheet and email and the ability to develop strong proficiency working with a proprietary Health Care system.
· Advanced customer service skills.
· Moderate ability to analyze and resolve technical problems and/or client inquiries as they arise.
· Intermediate 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), Cal-COBRA, Multiple Employer Welfare Arrangement (MEWA) and Employee Retirement Income Security Act (ERISA) regulations.
· Knowledge of health insurance industry and standard health care eligibility provisions.
· 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.
D UT IE S A ND R E S P O NS IB IL IT I E S
Account Operations & Maintenance
· Maintain/manage all Key Account contribution/premium reimbursements, COBRA payments and enrollments, and vendor pass thru payments for Key Accounts.
· Manage complex account reconciliations, special assignments, and build ad hoc reports.
· Manage all Key Account contributions, premium reimbursements, and other client contributions.
· Verify and authorize the release of key account provider payments within four (4) four business days of account funding.
· Generate and distribute scheduled, specific reports to leadership from the claims processing system.
· Review and process National Automated Clearing House Association files daily.
· Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, or reduce expenses.
· Manage and maintain bank lockbox, and ACH/Wire programs.
· Collaborate with Key Account leadership to provide tactical recommendations based on analysis of the data, business situation, and moderate knowledge of systems.
· Lead and respond to escalated customer inquiries regarding billing issues.
· Coordinate activities and provide training for lower-level staff.
· Assist with system testing of IT related projects and the implementation of application software releases within the Finance organization.
· Create and document Standard Operating Procedures (SOP’s).
· Identify, initiate, and implement process improvements and/or innovations.
Transaction Processing
· Review and process all claims in the company’s financial processing systems.
· Review and process client applications and correct eligibility as needed to resolve complex cases.
· Review and enter manual requests for reimbursement into the company’s financial processing system on the provider’s behalf and process the request via OPS Connect.
· Review and process new reimbursement requests cases in OPS Connect
· Reach out to providers that need additional explanation regarding the documents needed for reimbursement review and processing.
· Process any requests the team sends for changes via the claims processing system.
· Process and verify necessary corrections on manual adjustments posted to the consumer’s account.
· Create repayment reports and perform account offsetting as assigned to clear accounts receivables.
· Assess and process refunds for terminations and overpayments on all accounts.
· Apply cash to appropriate ledgers and research application issues.
· Create and maintain logs, records, or databases of information about fraudulent activity
· Gather financial documents related to investigations.
· Analyze financial data to detect irregularities in areas such as billing trends, financial relationships, and regulatory compliance procedures.
· Process related written and verbal account inquiries to a conclusion in a timely manner, including research as needed.
· Provide assistance to the Operations Lead, as required.
Customer Service
· Process related written and verbal account inquiries to its conclusion in a timely manner to include research on as needed basis.
· Work with the Operations Specialists I’s and Field Operations Specialists to resolve unpaid and outstanding balances for providers, and other clients.
· Maintain accurate records of information, activities, and changes in the database and inquiry outcomes for accurate tracking and analysis.
· Research and analyze data to address operational challenges and customer service issues.
· Provide guidance and answer questions for providers needing customer contact, including, but not limited to making outbound calls, sending messages via internal systems for tracking and continuity and returning messages.
· Act as liaison with Accounting, as needed, for resolution of issues that may arise.
· Provide timely and effective customer service to clients for requests, inquiries or issues concerning enrollment and/or billing items on their account.
· Consistently meet processing cycle time standards and production due dates.
· Mentor Financial Operations Specialists I’s and Field Operations Specialists.
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.
P H YS IC A L D E MA ND S /W OR K E N V I R O N ME N T
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.
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