Claims Customer Service Representative I

Overview

To research and resolve provider telephone and written inquiries within established timeframes,accurately screen claims, and participate in provider meetings and projects. Support for eitherescalated calls or to accept calls of a more complex nature requiring additional skills. To providesupport to CSR staff when call volume requires additional personnel. Routinely process CIFs aspart of their daily workload.

Responsibilities

•  ESSENTIAL DUTIES AND RESPONSIBILITIES- Respond to provider telephone inquiries; research policy issues, analyze EOPs and claimhistory, recommend resolution to the issues, implement resolution once approved andcommunicate outcome to providers within established timeframes.- Research, resolve, and communicate outcome to providers on CIFs, claim tracers, andgeneral claim correspondence within established timeframes.- Participate in provider meetings to resolve claim issues. Along with Provider Relationsstaff, participate in quarterly provider focus group meetings and in-services.- Follow established Partnership policies and procedures, Partnership claims operating instructionmemorandums, EDS provider manual guidelines, and Title 22 regulations when resolvingclaims and claim issues. Complete claim processing accurately within establishedproduction standards.- Enter, process, and resolve claims from all Partnership claim types and in any form (paper orelectronic) within established standards. This will include electronic and paper crossoverclaims, pended claims, and claims which require manual pricing.- Participate in special projects and assignments as required.- Recognize and give feedback to management on procedure changes that would result inmore efficient operations.- Record daily production statistics and related activities on appropriate reports; turn all logsand reports in to Claims Customer Service Supervisor.
• SECONDARY DUTIES AND RESPONSIBILITIES- Participate in special projects and assignments as required.- Will participate in resolution of CIFs as required

Qualifications

Education and Experience

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

Special Skills, Licenses and Certifications

Knowledge of CPT, HCPC procedure coding, and ICD-9 diagnosticcoding. Knowledge of medical terminology. Ability to access codingreference guides for accurate information. Typing speed 30 wpm and proficient use of 10-key calculator.

Performance Based Competencies

Effective written and oral communication skills. Ability to effectivelyexercise good judgment within scope of authority and handle sensitiveissues with tact and diplomacy. Good organization skills. Ability toaccurately complete tasks within established times.

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 5 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 HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$29.95 - $35.19

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.