Pinnacle Claims Management is an innovative third-party administrator providing comprehensive health benefits administration services. The Bilingual Field Enrollment Specialist is responsible for educating clients on program guidelines, processing claims, and delivering high-quality customer service support to ensure client satisfaction.
Responsibilities
- 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
- 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
Skills
- High school diploma or equivalent
- 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
- Knowledge of generally accepted health care eligibility and billing procedures
- Knowledge of 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
- 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
Benefits
- Affordable health benefit solutions
- Flexible work arrangements with work-from-home, in-office or hybrid options
- Competitive compensation packages
- Premier investment support
- Enriching personal development
- Profit-sharing
Company Overview
Pinnacle Claims Management provides a spectrum of health benefits administration services to self-funded employers in all industries. It was founded in 1996, and is headquartered in Irvine, California, USA, with a workforce of 201-500 employees. Its website is https://www.pinnacletpa.com/.