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Ultimate Staffing · 1 day ago

Sr. Participant Service Specialist

Burbank, CA

Full-time

Onsite

Mid, Senior Level

$58K/yr - $65K/yr

4+ years exp

Ultimate Staffing is an established organization seeking a Senior Participant Service Specialist on a direct hire basis. The role involves processing health insurance claims and handling inbound inquiries from various stakeholders while ensuring compliance with policies and fostering strong relationships through effective issue resolution.

EmploymentHuman ResourcesManufacturingStaffing Agency

Comp. & Benefits

Hiring Manager

Ashly Rodriguez

Responsibilities

Deliver exceptional service by meeting established performance metrics in efficiency, accuracy, quality, productivity, system compliance, customer satisfaction, and attendance

Represent the organization with professionalism and elevate its reputation by providing world-class customer service

Respond to incoming calls and accurately identify customer needs, including benefit eligibility, billing inquiries, payment issues, treatment authorizations, and explanation of benefits (EOBs)

Actively listen, ask clarifying questions, and document information in real time

Communicate clearly and collaborate with customers to resolve issues, ensuring understanding through simple and concise language

Fulfill requests by clarifying information, forwarding inquiries, and following through on commitments

Investigate and resolve problems by interpreting issues, researching solutions, and implementing corrective actions

Review and process healthcare claims by navigating multiple systems, verifying data, and applying appropriate pricing, authorizations, and benefits

Ensure compliance with claims processing policies, grievance procedures, federal mandates, CMS/Medicare guidelines, and benefit plan documents

Go above and beyond to engage and support customers

Train and mentor new team members as needed

Analyze existing business procedures to identify gaps or inconsistencies; prepare updated documentation, flowcharts, and process guidelines

Assess workflows and recommend improvements to enhance efficiency and customer experience

Evaluate and prepare for changes in software applications or regulatory requirements impacting business processes

Conduct research on benefit trends, service enhancements, and their impact on the organization

Identify internal control weaknesses and propose corrective measures

Maintain a comprehensive library of policies and procedures, ensuring accuracy and currency

Collaborate with the team to improve business process flow and resolve customer issues effectively

Qualification

Claims processingHigh-volume call centerCustomer serviceMicrosoft WordMicrosoft ExcelMicrosoft OutlookAnalytical skillsTelephone etiquetteMedical terminologyBenefits plans knowledgeOrganizational skillsTime-management skillsVerbal communicationWritten communicationProblem-solving skills