Senior Participant Service Specialist-112720

Claims Processing, Minimum of four (4) years of claim processing and healthcare call center environment experience
Full Time
Depends on Experience
Work from home not available Travel not required

Job Description

Senior Participant Service Specialist-112720

Direct Hire



The Senior Participant Service Specialist will process health insurance claims and answers calls from physicians, hospitals and customers. Adhere to claim and call policies and procedures while making sound claim/call decisions. Foster strong customer relationships through the resolution of customer incoming call requests. Serve our customers by determining requirements, answering inquiries, resolves problems, fulfilling requests and maintaining key performance measures. Build strong working relationships with others within the company, by demonstrating effective people skills and interpersonal savviness.



  • Meet all key performance indicators established for this position in the areas of: efficiency, accuracy, quality, productivity, system adherence, customer satisfaction and attendance
  • Elevate and enhance the Health Funds reputation by providing World Class Customer Service
  • Answer incoming phone calls from customers and identify the type of assistance the customer needs (e.g. benefit and eligibility, billing and payment inquiries, authorizations for treatment and explanation of benefits (EOBs)
  • Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information real time in computer systems
  • Communicate and collaborate with customers and providers to resolve issues, using clear, simple language to ensure understanding
  • Fulfills requests by clarifying desired information; completing call logs by entering required data in real time; forward requests and follow through on all customer commitments
  • Resolves problems by interpreting and clarifying issues; researching and exploring answers and alternative solutions; implementing solutions; addressing unresolved problems
  • Review and research incoming healthcare claims by navigating multiple computer systems and platforms and verify the data/information necessary for processing (e.g. pricing, prior authorizations, and applicable benefits)
  • Go the extra mile to engage customers
  • Ensure that the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, grievance procedures, federal mandates, CMS/Medicare guidelines, and benefit plan documents/certificates)
  • Train and coach new staff


  • Excellent customer service and telephone skills
  • Individual must be reliable, dependable, and punctual
  • Ability to balance and prioritize multiple tasks
  • Ability to work in an environment with fluctuating workloads
  • Ability to effectively balance workload in a fast-paced work environment
  • Excellent verbal and written communication skills
  • Ability to solve problems systematically, using sound business judgment
  • Ability to make decisions with every call and handle escalated issues
  • Knowledge of medical terminology
  • Ability to research and verify claims payment issues


  • AA or BA degree preferred in related field
  • Minimum of four (4) years of claim processing and healthcare call center environment experience
  • Strong knowledge of benefits plans, policies and procedures
  • Demonstrated organization and time management skills
  • Strong phone contact handling skills and active listening
  • Proficient with Microsoft products, including Word and Excel
  • Proven verbal and written communication skills

Posted By

Shirley Shmagin

17441 Bramble Court Yorba Linda, CA, 92886

Dice Id : 10115978
Position Id : 112720
Originally Posted : 1 month ago
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