Job Details

Job Description

Participant Service Specialist

Position Overview
We are seeking a customer-focused Senior Participant Service Specialist to support health insurance claims processing and high-volume customer interactions. This role serves as a frontline resource for participants, providers, and healthcare partners, while also contributing to business process analysis and continuous improvement initiatives.

Key Responsibilities

• Process and review health insurance claims for accuracy, eligibility, pricing, and benefits
• Handle a high volume of inbound calls related to benefits, eligibility, billing, authorizations, and explanations of benefits (EOBs)
• Resolve customer inquiries by researching issues, interpreting policy guidelines, and applying appropriate solutions
• Document interactions and claims activity accurately in real time across multiple systems
• Ensure compliance with claims policies, federal mandates, and benefit plan documentation
• Meet performance standards for quality, productivity, accuracy, and customer satisfaction
• Train and support new team members as needed
• Partner with internal teams to improve workflows, documentation, and customer experience

Analytical Responsibilities

• Analyze business processes, identify gaps, and recommend improvements
• Develop and maintain process documentation, policies, and workflows
• Evaluate impacts of system enhancements and regulatory changes
• Research benefit and service trends to support operational improvements

Qualifications

• Bachelor's degree required
• 4+ years of health insurance claims processing experience (preferred)
• 4+ years of recent experience in a high-volume call center environment (required)
• Strong knowledge of benefit plans, claims processing, and medical terminology
• Excellent problem-solving, communication, and customer service skills
• Proficient in Microsoft Word, Excel, and Outlook
• Ability to manage multiple priorities in a fast-paced environment
• Reliable, organized, and adaptable with strong decision-making skills

Work Schedule

• Full-time (40 hours/week), Monday-Friday
• Core business hours between 8:30 a.m. - 5:00 p.m.
• Flexibility to support occasional overtime or weekend coverage

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.

Job Reference: JN -012###-####49