Introduction to Gold Coast Health Plan
Gold Coast Health Plan (GCHP) is a leading health plan provider dedicated to delivering high-quality, patient-centered care to its members. With a strong commitment to creating an inclusive and collaborative work culture, GCHP empowers its employees to grow and thrive in their careers. As a key player in the healthcare industry, GCHP is seeking an experienced Operations and Provider Support Call Center Representative to join its team. In this role, you will act as a liaison between GCHP and the provider community, resolving provider issues, addressing concerns, and resolving problems telephonically and via email.
Job Summary
Under the direction of the Senior Operations Manager, the Operations and Provider Support Analyst II will perform a variety of research and analytics, auditing, and resolution activities related to claims processing and provider functions. This includes responding to inquiries related to claim submissions and processed claims, identifying claim errors, root causes, and recommended solutions. The ideal candidate will have excellent analytical, communication, and problem-solving skills, with the ability to work effectively in a fast-paced call center environment.
Key Responsibilities
- Act as a liaison between GCHP and the provider community to effectively resolve provider issues, address concerns, and resolve problems
- Analyze claims issues in coordination with designated Claims leadership in accordance with GCHP policies and procedures, regulatory requirements, and industry standards for Claims adjudication
- Answer provider service lines as necessary and respond to provider inquiries either by phone or email regarding claims-related questions
- Properly document all calls/contacts as required by department standards in a timely, clear, and concise manner using 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
- Perform daily/weekly prepayment audit of claims within the guidelines provided and assist in the development and enhancement of the prepayment audit programs for oversight and monitoring of claims-related activities and coordination of weekly check run processes
- Address provider complaints and provide instruction and oversight to providers when necessary
- 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 all regulatory and contractual requirements
- Assure timely and accurate resolution of claims issues jointly with internal and external Claims and/or configuration staff
Essential Qualifications
To be successful in this role, you will need:
- High School Graduate or General Education Degree (GED)
- 4-5+ years of experience in a claims processing department
- 4-5+ years of experience in provider relations or related experience
- Medi-Cal/Medicaid managed care experience strongly desired
- Advanced claims and billing knowledge in order to research and resolve claims and authorization issues and/or elevate to other Plan management
- Advanced knowledge of the provider network database and provider portal
- Computer 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 are preferred:
- Certifications or licenses related to claims processing or healthcare administration
- Experience working in a call center environment
- Knowledge of medical billing/coding (CPT, HCPCS, ICD-9/ICD-10); COB/TPL regulations and guidelines
- Knowledge of provider reimbursement methodologies and Medi-Cal regulations
Skills and Competencies
To excel in this role, you will need to demonstrate the following skills and competencies:
- Analytical skills: ability to use thinking and reasoning to solve problems
- Business acumen: ability to grasp and understand business concepts and issues
- Communication skills: ability to communicate effectively with others using the spoken and written word
- Research skills: ability to design and conduct a systematic, objective, and critical investigation
- Diversity-oriented: ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type
Career Growth Opportunities and Learning Benefits
At GCHP, we are committed to the growth and development of our employees. As an Operations and Provider Support Call Center Representative, you will have access to:
- Comprehensive training programs to enhance your skills and knowledge
- Opportunities for career advancement and professional growth
- A collaborative and supportive work environment that encourages learning and development
- Recognition and reward programs to acknowledge your achievements and contributions
Work Environment and Company Culture
GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. Our company culture is built on the following core values:
- Integrity: we act with honesty, transparency, and ethics in all our interactions
- Accountability: we take responsibility for our actions and outcomes
- Collaboration: we work together as a team to achieve our goals
- Trust: we build trust with our members, providers, and each other
- Respect: we treat each other with dignity and respect
Compensation, Perks, and Benefits
We offer a competitive salary and a comprehensive benefits package, including:
- Medical, dental, and vision insurance
- 401(k) retirement plan with company match
- Paid time off and holidays
- Flexible work arrangements, including remote work options
- Professional development opportunities and tuition reimbursement
Conclusion
If you are a motivated and detail-oriented individual with a passion for delivering exceptional customer service, we encourage you to apply for this exciting opportunity. As an Operations and Provider Support Call Center Representative, you will play a critical role in resolving provider issues and addressing concerns, while working in a collaborative and supportive environment. Don't miss out on this chance to join our team and take your career to the next level. Apply now!
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