CCSB Eligibility Specialist

Eligibility & Enrollment Irvine, California


Job Description Summary

The Eligibility Specialist I is responsible for performing enrollment and billing functions necessary to maintain Covered California for Small Business (CCSB) accounts on the Healthcare Common Procedure Coding System (HCPS) as assigned. The role is also responsible for providing the highest level of customer service support to clients by instructing them on correct eligibility management and explaining billing/payment issues.



  • High school diploma or equivalent and two 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), Consolidated Omnibus Budget Reconciliation Act (COBRA), California Continuation Benefits Replacement Act (Cal-COBRA) 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 and/or client problems as they arise with minimal direction.
  • Proficient written and oral communication skills to include modern business communications, formatting of professional letters, reports and phone etiquette.
  • Skills to establish priorities, multi-task, work under pressure and deadlines, work independently with minimal supervision or in team environment.
  • General knowledge of health insurance operations and industry.
  • Spanish bilingual (verbal/written) abilities a plus.

Duties And Responsibilities

Process Management & Maintenance

  • Assist in maintaining Eligibility and Billing for CCSB 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 the client or internal sources in accordance to Participation Agreements, Employer Policy Statement, Eligibility Guidelines and/or Summary Plan Descriptions.
  • Assist in producing electronic spreadsheets and/or reports for audit and processing purposes.
  • Research and correct cash application issues in HCPS. Determine/correct out of balance ledger items on accounts. Contact clients to explain and to resolve billing/payment discrepancies. Verify/authorize refunds for terminations and/or overpayments.
  • Maintain a HIPAA compliant work station and utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.
  • Consistently meet processing cycle time standards and production due dates as set forth by management.

Customer Service

  • Assist in supporting with clients to facilitate payments on time and for the billed
  • Provide timely and effective Customer Service to clients for requests, inquiries or issues concerning enrollment and/or billing items on their account
  • Interface effectively with internal departments and external vendors, brokers or other business contacts to coordinate interrelated activities and to resolve eligibility and/or billing issues as they
  • Serve as 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 Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results.
  • Other duties as assigned

Physical Demands/Work Environment

The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. 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.