Claims Customer Service Representative-Hybrid Fresno/Bakersfield

Description

Who We Are

Innovative Integrated Health (IIH) is a mission-driven healthcare organization dedicated to helping frail, underserved, and multiethnic seniors live safely and independently at home with dignity. Through the Program of All-Inclusive Care for the Elderly (PACE) model of care, we deliver high-quality, personalized healthcare and supportive services that improve quality of life across the communities we serve.

At IIH, our work is rooted in compassion, cultural understanding, and deep respect for those in our care. Team members play a vital role in supporting seniors throughout Central and Southern California—delivering care that’s not only clinically excellent, but also personal, coordinated, and community-based.

When you join IIH, you become part of a team committed to making a real difference in the lives of older adults—every single day.

Benefits

• 401(k) 
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid sick time
• Paid time off
• Referral program
• Retirement plan
• Vision insurance

Job Summary

The Claims Customer Service Representative (CCSR) serves as a critical liaison between Innovative Integrated Health, Inc. (Company) and external healthcare providers (Providers). The CCSR handles incoming inquiries from Providers who submit claims to the Company.  The CCSR is expected to act with a high level of professionalism, confidentiality, and efficiency.  The role requires excellent judgment, strong communication skills, and the ability to manage multiple priorities in a fast-paced environment.  The CSSR is expected to demonstrate a high level of accuracy and attention to detail while upholding regulatory and privacy standards as mandated by the Health Insurance Portability and Accountability Act (HIPAA). Candidate may work a combination of at either Fresno or Bakersfield site & from residence.

Essential Job Functions

Duties include, but are not limited to:

• Respond to Provider inquiries regarding medical and dental claims via phone and email.
• Research and resolve issues related to claims status, denials, and payment discrepancies. 
• Maintain up-to-date knowledge of benefit plans, claim adjudication guidelines, coding requirements, and HIPAA regulations.
• Accurately document all interactions and claim actions in the Company system by compliance standards.
• Maintain accurate records of interactions and claim resolutions.
• Communicate complex benefit details in a clear and concise manner to Providers.
• Collaborate with internal departments to facilitate resolution of claims-related issues.
• Recommend process improvements to enhance service delivery and improve Provider experience.
• Provide empathetic and efficient service to when working with Providers.
• Ensure all duties are completed with a focus on quality, compliance, and Provider satisfaction.
• Maintain punctuality, professionalism, and adherence to company policies and attendance requirements.
• Attend and participate in audits, staff meetings, in-services, and other projects as assigned.   
• Adhere to and support the center’s practices, procedures, and policies including assigned break times and attendance.
• Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
• Flexibility to adjust schedule as needed to meet operational demands.

Knowledge, Skills and Abilities 

• Proficient in Microsoft Office (Excel, Outlook, Word); knowledge of claims processing software, preferred.
• Familiarity with medical billing terminology (ICD-10, CPT, HCPCS) and Explanation of Payments (EOPs).
• Strong oral and written communication skills.
• Proven ability to multi-task and remain detail-oriented under pressure.
• Strong interpersonal and problem-solving skills; collaborative mindset.
• Ability to learn and apply regulatory requirements quickly.

Working Conditions and Physical Demands 

The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to access all areas of the center throughout the workday.
• Ability to lift a minimum of 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance of another employee when attempting to lift or transfer objects over 50 pounds.
• Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching forward and overhead; squatting and kneeling.
• Ability to communicate verbally with an excellent comprehension of the English language. 
• Work is generally performed in an indoor, well-lit, well-ventilated, heated, and air-conditioned environment.

Requirements

Experience

• Minimum of two (2) years work experience required. 
• Minimum of one (1) year of experience working in a healthcare call center, preferred
• Experience working remotely, preferred.

Education and Certification 

• At a minimum a High School Diploma or GED is required.
• Is medically cleared for communicable diseases and has all immunizations up-to-date before engaging in direct participant contact.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. 

Core Values

• Respect at the core of our interactions.
• Honesty and Integrity with every endeavor
• Patient – Centered care aligned with participant values, beliefs, and preferences. 
• Encouragement that motivates and empowers others to be the best they can be. 
• Quality Care that is efficient, transformative and innovative.