[Remote] CCSB Eligibility Specialist I

Note: The job is a remote job and is open to candidates in USA. Pinnacle Claims Management is an innovative third-party administrator providing comprehensive health benefits administration services. The CCSB Eligibility Specialist I will maintain and administer employee benefits within the CCSB Covered CA Small Business exchange, processing enrollments, terminations, and resolving member inquiries related to benefit plans.

Responsibilities

• 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 the system of record as received from the client or internal sources in accordance with Participation Agreements, Employer Policy Statement, Eligibility Guidelines and/or Summary Plan Descriptions
• Provide support to CCSB Small Business call center team based on business needs, ensuring efficient and effective customer service operations
• Meet production and audit metric goals as set forth by management
• Review audit results and make corrections within the processing cycle time standards and due dates as set forth by management
• Communicate 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 arise
• Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses
• Create and document Standard Operating Procedures (SOPs)
• Identify, initiate, and implement at least one process improvement and/or innovation annually
• Maintain 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
• 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

Skills

• High school diploma and/or equivalent and one (1) to three (3) years of Accounting/Business 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
• Intermediate experience with Microsoft Office suite and the ability to develop a strong proficiency working with a proprietary healthcare 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 including 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 a team environment
• General knowledge of health insurance operations and industry
• Ability to work required 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
• Fluent in Spanish, both verbal and written a plus

Benefits

• A rich benefits package that includes profit-sharing
• Flexible work arrangements with work-from-home, in-office or hybrid options

Company Overview