Primary Duties and Responsibilities

• The Specialist is responsible for resolving inquiries related to claims, eligibility, and authorization and working with multiple parties to ensure records are up to date.
• The Specialist will ensure first-call-resolution standards are followed and will refer and follow-up as per Hoag guidelines.
• Ensure accuracy, reports issues, and works to resolve.
• Ensure compliance and regulatory guidelines and health plan requirements are met.
  Documents actions taken following HIPAA guidelines.
• May assist in providing customer service, member services, and others in working with providers/billing offices when needed.
• Assist in identifying and reporting issues working with the management team to help minimize re-work and address front-end process issues.
• Performs other duties as assigned.

Revenue Cycle

• May also maintains databases, audit information and works with patients to process patient payment.
• May follow up with insurance companies on outstanding or unpaid claims, create/send statements to patients.

Clinic MSO 

• The Claims Billing Specialist handles 35-40 calls daily from healthcare providers, health plans, billing companies, and members on inquiries related to claims, eligibility, and authorization
• Document all incoming calls following HIPAA guidelines in handling patient data 
• Support the claims department by preparing claim receipts and correspondences received in the Hoag Clinic MSO mailroom 
• Assist with daily pick-ups and distribution of mail and correspondences from dedicated post office boxes, fax machines, e-fax, secure file transfers, as well as sending provider EOBs, member letters, misdirected claims, and other letters sent by the Claims team 
• Interact in a positive and collaborative manner with internal and external partners especially in demanding and tense situations with providers and patients exhibiting a caring, empathetic, and patient attitude 
• Support the claims team in implementing initiatives in improving claims processing efficiency 
• Assist in provider customer service, member services, health plan, and other customers including making and answering phone calls to providers/billing offices when necessary, based on team guidelines 

Hoag Memorial Hospital Presbyterian is a nonprofit regional health care delivery network in Orange County, California, consisting of three acute-care hospitals with sixteen urgent care centers, eleven health centers and a network of more than1,800 physicians, 100 allied health members, 8,000 employees, and 2,000 volunteers. More than 30,000 inpatients and 550,000 outpatients choose Hoag each year.

For over 70 years, Hoag has delivered a level of personalized care that is unsurpassed among Orange County’s health care providers. Since 1952, Hoag has served the local communities and continues its mission to provide the highest quality health care services through the core strategies of quality and service, people, physician partnerships, strategic growth, financial stewardship, community benefit and philanthropy.

Hoag offers a comprehensive blend of health care services including six institutes providing specialized care in the areas of cancer, heart and vascular, neurosciences, women's health, orthopedics, and digestive health through our institutes.

Hoag was the highest ranked hospital in Orange County in the 2024-2025 U.S. News &World Report, the only Orange County hospital ranked in the top 10 for California. The organization was ranked the #5 hospital in the Los Angeles Metro Area and the #10 hospital in California.

To learn more about Hoag’s awards and accreditations, visit: https://www.hoag.org/about-hoag/awards-accreditations/.

Hoag is an Equal Opportunity Employer and prohibits discrimination and harassment of any kind. Hoag is committed to the principle of equal employment opportunity for all employees and providing employees with a work environment free of discrimination and harassment. Hoag hires a diverse group of people in a manner that allows them to reach their full potential in the pursuit of organizational objectives.