Claims Customer Service Representative I

Overview

To research and resolve provider telephone and written inquiries within established time frames, accurately screen claims, and participate in provider meetings and projects. To accurately research and process paper and electronic medical, outpatient, ancillary, long term care, CHDP, encounter data and paper crossover/other coverage claims within established time frames, applying appropriate program policies related to claims processing and analysis.

Responsibilities

• Responds to provider telephone inquiries, researches policy issues, and analyzes EOP's and claim history, recommends resolution to the issues, implements resolution once approved.
• Researches and communicates outcome to providers of CIF's, claim tracers, and general claim correspondence within established time frames
• Follows established Partnership policies and procedures, Partnership claims operating instruction memorandums, EDS provider manual guidelines, and Title 22 regulations when resolving claims and claim issues.
• Participates in provider meetings to resolve claim issues.
• Recognizes and gives feedback to management on procedure changes that would result in more efficient operations.
• Records daily production statistics and related activities on appropriate reports; turns all logs and reports in to Claims Customer Service Supervisor.
• Meets established production and call performance metrics as determined.
• Participates in special projects and assignments as required.
• Participates in resolution of CIFs as required.
• Other duties as assigned.

Qualifications

Education and Experience

High school diploma or equivalent; one (1) year of prior claims processing experience in an automated claim environment preferred; or equivalent combination of education and experience.

Special Skills, Licenses and Certifications

Knowledge of CPT, HCPC procedure coding, and ICD-10 diagnostic coding. Knowledge of medical terminology preferred. Ability to access coding reference guides for accurate information. Typing speed 30 wpm and proficient use of 10-key calculator.

Performance Based Competencies

Excellent written and oral communication skills. Ability to effectively exercise good judgment within scope of authority and handle sensitive issues with tact and diplomacy. Good organizational skills. Ability to accurately complete tasks within established time frames.

Work Environment And Physical Demands

Ability to use a computer keyboard. More than 80% of work time is spent in front of a computer monitor; when required, ability to move, carry, or lift objects of varying size weighing up to 25 lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlans policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$28.94 - $34.00

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

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