Claims Customer Service Representative

Assist providers with inquires specific to their medical claims.

Essential Functions & Responsibilities

  • Provide claims information through telephone inquiry from providers of service.
  • Provide claim information through inquiries receive via facsimile from providers of service.
  • Recognize potential problems and refers them to the appropriate person to include Claims Management for resolution, and follows up to assure resolution
  • Maintains a broad knowledge of all systems used in the adjudication of claims.
  • Maintains quality standards of claims calls handled.
  • Maintain a log of calls for use in the reporting and tracking of calls handled.
  • Liaison to other departments outside of the claims department.
  • Provides back-up to the Claims Department staff, (claims examiners, data entry & clerical)
  • Special projects and other duties as assigned by management.
  • Some overtime may be required.
  • Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
  • Ability to come to work and work the regular schedule and shift for the position.
  • Compliance with all personnel policies and procedures.
  • Perform additional duties and related essential duties as assigned.

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Required Education and Experience

  • High school diploma or general education degree (GED); or one to three months related experience and/or training; or equivalent combination of education and experience.
  • Minimum 5 years experience in medical claims environment.
  • Minimum 3 years customer service experience.
  • Demonstrated knowledge of ICD-9, CPT-4 and HCPCS coding.

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