Operations & Provider Support Call Center Representative - Remote/Ventura County, CA - Gold Coast Health Plan

Join Our Team: Operations & Provider Support Call Center Representative At Gold Coast Health Plan (GCHP), we're dedicated to providing high-quality healthcare services to our members while fostering a collaborative and inclusive work environment. As we continue to grow and expand our operations, we're seeking a skilled and experienced Operations & Provider Support Call Center Representative to join our team. This role will be the primary point of contact between GCHP and our provider community, resolving issues, addressing concerns, and providing exceptional support. About Our Company and Industry GCHP is a leading health plan provider in Ventura County, California, committed to delivering innovative and effective healthcare solutions. Our team is passionate about making a positive impact on the lives of our members, and we're looking for talented individuals to join our mission. As a Call Center Representative, you'll be an integral part of our operations team, working closely with providers, internal stakeholders, and external partners to ensure seamless claims processing, provider support, and issue resolution. Key Responsibilities Act as a liaison between GCHP and the provider community to effectively resolve provider issues, address concerns, and resolve problems telephonically and via email. Assist in prioritizing provider claims research projects, recognizing compliance and business priorities, and communicate root cause errors to GCHP and BPO leadership. Create and update claim-related policies, procedures, workflows, and job aid manuals to ensure accurate and compliant claims processing. Develop and maintain practices on quality metrics related to provider training, recommending prospective and retrospective auditing processes to assure accurate and compliant processing of claims, disputes, and adjustments. Analyze claims issues in coordination with designated Claims leadership, adhering to GCHP policies, regulatory requirements, and industry standards for Claims adjudication. Respond to provider inquiries via phone or email, addressing claims-related questions, and properly document all calls/contacts in GCHP's internal tracking system. Perform post-payment auditing in accordance with GCHP audit programs, policies, and procedures, regulatory requirements, and industry standards for Claims adjudication. Participate in daily/weekly prepayment audits, assisting in the development and enhancement of prepayment audit programs for oversight and monitoring of claims-related activities. Address provider complaints, providing instruction and oversight to providers when necessary, and communicate with providers on resolution and closure of issues. Provide guidance to internal and external Claims resources in determining proper courses of action in resolution of Provider claims issues. Analyze information to assure resolutions are in compliance with regulatory and contractual requirements, ensuring timely and accurate resolution of claims issues. Essential Qualifications To succeed in this role, you'll need: A High School Diploma or General Education Degree (GED); a Bachelor's degree or equivalent experience is preferred. 5-7+ years of experience in a claims processing department, with a strong understanding of claims processing, provider relations, and Medi-Cal/Medicaid managed care. Advanced knowledge of claims and billing, including CPT, HCPCS, ICD-9/ICD-10 coding, and COB/TPL regulations. Proficiency in MS Office programs, with advanced Excel skills. A current and valid California Driver's License and Insurance. Preferred Qualifications While not required, the following qualifications will give you a competitive edge: Medi-Cal/Medicaid managed care experience. Advanced knowledge of provider network databases and provider portals. Experience with health plan division of financial responsibility (DOFR) and industry "best practices." Skills and Competencies To excel in this role, you'll need: Analytical skills to solve complex problems. Business acumen to understand business concepts and issues. Effective communication skills, both written and oral. Research skills to design and conduct systematic investigations. The ability to work effectively with people of diverse backgrounds, ages, and job types. Career Growth Opportunities and Learning Benefits At GCHP, we're committed to helping our employees grow and develop their skills. As a Call Center Representative, you'll have opportunities to: Develop your knowledge of claims processing, provider relations, and Medi-Cal/Medicaid managed care. Enhance your analytical, communication, and problem-solving skills. Participate in training and development programs to stay up-to-date on industry trends and best practices. Work Environment and Company Culture GCHP promotes a flexible work environment, allowing employees to work from home or in our office. We're committed to creating an inclusive and collaborative culture that values: Integrity Accountability Collaboration Trust Respect Compensation, Perks, and Benefits We offer a competitive compensation package, including a salary range that's commensurate with your experience and qualifications. Our benefits package includes: A comprehensive benefits program. Opportunities for professional growth and development. A flexible work environment. Training and Onboarding Our comprehensive training program will equip you with the knowledge and skills needed to succeed in this role. Training will take place from November 18th to January 6th at our Camarillo, CA location. Join Our Team! If you're a motivated and experienced professional looking to make a difference in the healthcare industry, we encourage you to apply for this exciting opportunity. As a Call Center Representative, you'll be an integral part of our team, working closely with providers, internal stakeholders, and external partners to drive success. Apply now and join our mission to deliver high-quality healthcare services to our members! Don't miss this opportunity to join our team and make a meaningful impact in the lives of our members. Apply today! Apply for this job