Sr. Participant Service Specialist

Business Solutions Manager at Ultimate Staffing

Established organization is seeking a Senior Participant Service Specialist on a direct hire basis in the greater Burbank, CA area. Pay ranges from $58-65k/year DOE. This is a customer-facing role serving as a key representative for the Health Fund. The Senior Participant Service Specialist/Analyst is responsible for processing health insurance claims and handling inbound inquiries from participants, providers, physicians, hospitals, and other stakeholders.

The position requires adherence to eligibility, claims, and call-handling policies while making sound decisions and fostering strong relationships through effective issue resolution.

$58,000.00/yr - $65,000.00/yr

• 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.

• Bachelor's degree in Healthcare, Math, Engineering, or related field, or equivalent experience.
• Minimum 4 years of claims processing (preferred).
• Minimum 4 years in a high-volume call center (required)
• Proficiency in Microsoft Word, Excel, and Outlook.
• Ability to learn and adapt to various software applications quickly.
• Strong analytical, organizational, and time-management skills.
• Excellent verbal and written communication abilities.
• Exceptional customer service and telephone etiquette.
• Ability to prioritize multiple tasks and thrive in a fast-paced environment.
• Problem-solving skills with sound business judgment.
• Knowledge of medical terminology, benefits plans, and claims processes.
• Reliable, dependable, and punctual.
• Adaptable and forward-thinking in response to technological or organizational changes.

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.

For unincorporated Los Angeles county, to the extent our customers require a background check for certain positions, the Company faces a significant risk to its business operations and business reputation unless a review of criminal history is conducted for those specific job positions.

Mid-Senior level

Full-time

Customer Service

Telephone Call Centers