Summary
The Claims Customer Service Advocate is responsible for responding to routine written and telephone inquiries related to claims, identifying and correcting processing errors, and reviewing claims and non-medical appeals in accordance with organizational policies and procedures. This role ensures accuracy, timeliness, and quality while delivering a high level of customer service.
Please note: A background check are required for this position.
Schedule: 40 hours per week, This is a full-time, on-site position working Monday–Friday from 8:00 AM–5:30 PM EST.
Key Responsibilities
- Respond to written and telephone inquiries in accordance with desk procedures, meeting timeliness, productivity, and quality standards
- Accurately document all inquiries and interactions
- Identify incorrectly processed claims and complete adjustments and reprocessing actions per departmental guidelines
- Review, adjudicate, and process claims and non-medical appeals in compliance with business regulations, contracts, and internal standards
- Enter claims into the system after verifying accurate procedure and diagnosis coding
- Ensure claims meet established quality and production standards
- Identify complex issues that cannot be resolved through standard procedures and escalate to a lead or manager as appropriate
- Identify and promptly report suspected fraudulent activity or system errors to the appropriate departments
Required Qualifications
- High School Diploma or equivalent
- One year of experience in claims or appeals processing, customer service, or a related support role
- OR a Bachelor’s Degree in lieu of work experience
- Strong verbal and written communication skills
- Excellent customer service skills
- Proficient spelling, grammar, and punctuation
- Basic business math proficiency
- Ability to handle confidential and sensitive information with discretion
- Proficiency with Microsoft Office and ability to navigate multiple systems
Core Skills & Abilities
- Answer and manage incoming phone calls
- Follow established policies and procedures
- Navigate claims and customer service systems efficiently
- Research and resolve inquiries
- Review and process claims and appeals
TRC Talent Solutions is proud to be an Equal Opportunity Employer (EOE). All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.