Job Description Summary

Qualifications

• High school diploma or equivalent and one (1) to three (3) years of customer service and/or 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.
• Excellent oral and written communication skills in English and Spanish, including 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.
• 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.
• Strong ability to research and resolve technical issues or client problems as they arise with minimal direction.
• Proficient written and oral communication skills including an ability to present material effectively in person.
• 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.
• 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.
• Verifiable, clean DMV record and the ability to travel to various locations throughout the U.S. (mainly California and Arizona) up to 50% of the time.

Duties And Responsibilities

Customer Service and Education Services

• Provide timely and effective customer service to clients for requests, inquiries, or issues concerning enrollment and reimbursement items on their accounts, in person, via email and via the phone.
• Provides support for overflow inbound calls as needed when not in the field.
• 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 Pinnacle, displaying professionalism, knowledge, customer service, and discretion in all interactions with other members of the client community and their customers.  
• Educate prospective enrollees and existing program participants on eligibility requirements, program benefits, processes, and procedures at multiple on-site locations in California, via phone or virtual conference room.
• Interface with third-party vendors/partners to communicate and educate them on benefits and programs specific to client programs and members.

Transaction Processing & Maintenance

• Review and process claims in person and in the office in the company’s financial processing systems.
• 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.
• Follow-up with members who need additional explanation regarding the documents needed for claims review and processing.
• Research and correct client application, eligibility and claims issues reported in the field.
• Contact clients to explain and resolve billing reimbursement discrepancies.
• Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and 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.

• 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). 
• Maintain a clean DMV record and the ability to travel to locations throughout the U.S. (mainly California and Arizona) up to 50% of the time.
• All other duties as assigned.    

Physical Demands/Work Environment