Claims Customer Service Representative

•  High school diploma or GED
•  Minimum of 2 years of claims processing (Medicaid and Medicare a plus)
•  A minimum of 2 years of customer service experience required
• Knowledgeable in Medicaid and Medicare guidelines
• Exceptional oral and written communication skills
• Proven ability to research, analyze and successfully root cause and resolve a broad spectrum of issues
• Able to multi-task and identify and trend processing and billing issues
• Solid computer skills (experience in Word, Excel)
• Organized
• Positive attitude
• Proven ability to follow-up and resolve provider inquiries
• Ability to work as a team player in a professional environment

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Answers all incoming provider calls in a timely, efficient and knowledgeable manner
• Reviews provider claim requests for appropriate information and accurate reimbursement
• Accurately adjudicates claims in accordance with health plan guidelines, company standards, and company procedures
• Excellent research and follow up on claim adjustment requests to ensure first call resolution
• Provides excellent customer service to external and internal customers
• Properly documents all incoming calls to the phone tracking system.
• Reviews history of claim in question; researches particulars; contacts appropriate personnel to verify information
• Identifies trends and processing issues related to the rework of claims.
• Prioritizes and manages individual workflow as need.
• Other duties as assigned

CORPORATE INTEGRITY:

• Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program
• Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
• Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position
• Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare