Bilingual Operations Specialist II

DescriptionAt Pinnacle Claims Management, we are an innovative third-party administrator (TPA) that provides a full-suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees.As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn’t a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee’s life. One way this is realized for employees of Pinnacle Claims Management is flexible work arrangements with work-from-home, in-office or hybrid options.With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees’ job satisfaction and success. Compensation:$ $46,669.19 - $ $60,668.60 with a rich benefits package that includes profit-sharing. Job Description SummaryThis position reports to the Supervisor I, Key Accounts. This position is responsible for serving as the first point of contact for Operations Specialist Is and Field Operations Specialists assigned to their Pod. This position will process financial transactions in the company’s financial processing systems as it relates to individual and group billing, automated clearing house (ACH), and cash receipt processing. The incumbent will also maintain and balance individual accounts receivables including delinquency processing and terminations. Additionally, they will manage all financial aspects of reimbursement requests submitted by consumers, generating desired reports, and processing and approving reimbursement payments via the company’s financial processing systems. The incumbent is responsible for managing all incoming claims and reimbursement requests and processing claims and client reimbursements, including complex claim cases requiring research and resolution. Lastly, they mentor and support the development of the Specialist level I in conjunction with the Team Lead. Q UA L IF IC AT IO NS BA/BSdegreeinaccounting,financeorbusiness-relatedfieldpreferredplus three (3) to four (4) years experience working in a related field or equivalent combination of education and experience, preferred. ExcellentoralandwrittencommunicationskillsinEnglishandSpanish,toincludemodernbusiness communications, formatting of professional letters, reports and phone etiquette, required. ComprehensivecommandoftheSpanishlanguagewiththeabilitytoutilizeitupto50%ofthe time. Demonstratedabilitytomulti-task,workinafast-pacedenvironment,meetestablisheddeadlines,and work independently with minimal supervision or in team environment. Proficientknowledgeofend-userofficesoftwarei.e.,calendaring,word-processing,spreadsheetand email and the ability to develop strong proficiency working with a proprietary Health Care system. Advancedcustomerservice skills. Moderateabilitytoanalyzeandresolvetechnicalproblemsand/orclientinquiriesasthey arise. IntermediateknowledgeofgenerallyacceptedHealthCareEligibilityandBillingproceduresaswellas Health Insurance Portability and Accountability Act (HIPAA), Consolidated Omnibus Budget Reconciliation Act (COBRA), Cal-COBRA, Multiple Employer Welfare Arrangement (MEWA) and Employee Retirement Income Security Act (ERISA) regulations. Knowledgeofhealthinsuranceindustryandstandardhealthcareeligibility provisions. Internetaccessprovidedbyacableorfiberproviderwith40MBdownloadand10MBupload speeds. HomerouterwithwiredEthernet(wirelessconnectionsandhotspotsarenot permitted). Adesignatedroomforyourofficeorstepstakentoprotectcompanyinformation(e.g.,facing computer towards wall, etc.) Afunctioningsmokedetector,fireextinguisher,andfirstaidkiton site. D UT IE S A ND R ESPO NS IB IL IT IE S AccountOperations& Maintenance Maintain/manage all Key Account contribution/premium reimbursements, COBRA payments and enrollments, and vendor pass thru payments for Key Accounts. Manage complex account reconciliations, special assignments, and build ad hoc reports. ManageallKey A ccountcontributions,premiumreimbursements,andotherclient contributions. Verifyandauthorizethereleaseofkeyaccountproviderpaymentswithin four (4)fourbusinessdaysof account funding. Generateanddistributescheduled,specificreportstoleadershipfromtheclaimsprocessing system. ReviewandprocessNationalAutomatedClearingHouseAssociationfiles daily. Identifyinefficiencieswithintheestablishedprocessesandsuggestpossiblesolutionstosavetime, reduce risk, or reduce expenses. Manage and maintain bank lockbox, and ACH/Wire programs. Collaboratewith Key Account leadership toprovidetacticalrecommendationsbasedonanalysisof the data, business situation, and moderate knowledge of systems. Leadandrespondtoescalatedcustomerinquiriesregardingbilling issues. Coordinateactivitiesandprovidetrainingforlower-level staff. AssistwithsystemtestingofITrelatedprojectsandtheimplementationofapplicationsoftware releases within the Finance organization. CreateanddocumentStandardOperatingProcedures(SOP’s) . Identify,initiate,andimplementprocessimprovementsand/orinnovations . Transaction Processing Reviewandprocessallclaimsinthecompany’sfinancialprocessing systems. Review and process client applications and correct eligibility as needed to resolve complex cases. Reviewandentermanualrequestsforreimbursementintothecompany’sfinancialprocessingsystem on the provider’s behalf and process the request via OPS Connect. ReviewandprocessnewreimbursementrequestscasesinOPS Connect Reachouttoprovidersthatneedadditionalexplanationregardingthedocumentsneededfor reimbursement review and processing. Processanyrequeststheteamsendsforchangesviatheclaimsprocessing system. Processandverifynecessarycorrectionsonmanualadjustmentspostedtotheconsumer’s account. Create repayment reports and perform account offsetting as assigned to clear accounts receivables. Assessandprocessrefundsforterminationsandoverpaymentsonall accounts. Applycashtoappropriateledgersandresearchapplication issues. Create and maintain logs, records, or databases of information about fraudulent activity Gather financial documents related to investigations. Analyze financial data to detect irregularities in areas such as billing trends, financial relationships, and regulatory compliance procedures. Processrelatedwrittenandverbalaccountinquiriestoaconclusioninatimelymanner,including research as needed. Provide assistance to the Operations Lead, as required. Customer Service Process related written and verbal account inquiries to its conclusion in a timely manner to include research on as needed basis. WorkwiththeOperations Specialists I’s and Field Operations Specialiststoresolveunpaidandoutstandingbalancesforproviders,and other clients. Maintainaccuraterecordsofinformation,activities,andchangesinthedatabaseandinquiry outcomes for accurate tracking and analysis. Researchandanalyzedatatoaddressoperationalchallengesandcustomerservice issues. Provide guidance and answer questions for providers needing customer contact, including, but not limitedtomakingoutboundcalls,sendingmessagesviainternalsystemsfortrackingandcontinuity and returning messages. Act as liaison with Accounting, as needed, for resolution of issues that may arise. Provide timely and effective customer service to clients for requests, inquiries or issues concerning enrollment and/or billing items on their account. Consistently meet processing cycle time standards and production due dates. Mentor Financial Operations Specialists I’s and Field Operations Specialists.OtherUtilizeallcapabilitiestosatisfyonemission—toenhancethecompetitivenessandprofitabilityofour 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.Maintaininternetspeedof40MBdownloadand10MBuploadandrouterwithwired Ethernet. MaintainaHIPAA-compliantworkstationandutilizeappropriatesecuritytechniquestoensureHIPAA- required protection of all confidential/protected client data.Maintainandservicesafetyequipment(e.g.,smokedetector,fireextinguisher,firstaid kit). Allotherdutiesas assigned. P H YS IC AL D E MA ND S /W OR K E NVIRON ME N T Thephysicaldemandsandworkenvironmentdescribedhererepresentthosethatanemployeemustmeetto successfully perform this job’s essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.