Overall Purpose:

We are looking for a skilled problem solver to join our team as a Claims Customer Service Representative. We need an enthusiastic individual who can interact with providers by listening to their issues/concerns and offer quick and accurate assistance. The candidate for this role will have a strong command of claims policies and be well-trained in providing excellent customer service. Interacting with providers over the phone and via email, answering incoming calls, emails, and returning voicemails regarding claims payment/denial issues, questions, and any other concerns, while maintaining a high level of professionalism.

Education and Experience:

• High school diploma/GED required
• 1 year Customer Service experience
• 1 year Call Center experience
• 1 year Claims processing experience

Knowledge, Skills and Abilities:

• Strong verbal and written communication skills with the ability to work with diverse personalities
• Enthusiastic and bold attitude with great customer service skills
• A problem solver with strong attention to detail
• Ability to address customer concerns creatively and share feedback with other teammates
• Works as a team member, as well as independently, with minimal supervision
• Demonstrate a strong customer service orientation and takes responsibility to ensure customer satisfaction
• Must have a strong understanding of any local, state and federal rules regarding claims
• Working knowledge of HMO operations, Claims, and Customer Service
• Must have a strong knowledge of CPT, ICD-10 and CMS Guidelines
• Ability to multi-task and adapt to changes quickly
• Strong analytical and multi-tasking skills
• Strong organizational and time management skills with the ability to prioritize and maintain several phone queues/return voicemails/and answer emails in a timely manner.
• Personal computer with main frame emulation, claims management software, word processing and management software, 10-key adding machine, Imaging retrieval software, fax machine, copy machine, basic office aids

Essential Functions:

• Engage with providers in a friendly and professional manner while actively listening to their concerns
• Answers incoming provider calls regarding claims status, payment issues, denials, general questions and concerns
• Responsible for maintaining a high level of professionalism with providers and working to establish a positive rapport with every caller
• Create a customer service incident in the customer service database during and after each call for tracking and reporting purposes
• Work with the management team to stay updated on claims processing guidelines and be informed of any changes in company policies
• Problem solving and ability to remain professional and courteous with customers at all times
• Performs other duties and responsibilities as directed, assigned or requested