Customer Service Specialist
4 weeks ago
Duration: 6+ months (Possible contract to hire)
Job Description:
· Imp notes: Monday-Friday 7:30-4:00.
· A typical day would like in this role: Have claims workload for day to work from and will be assigned priority claims, will also work info buckets as needed.
· Previous claims processing experience//familiarity with excel spreadsheets/word suite.
· Skill sets/qualities: Claims processing experience/customer service.
· Provides prompt, accurate, thorough and courteous responses to all complex customer inquiries.
· Inquiries are typically non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries.
· Reviews and adjudicates complex or specialty claims and/or non-medical appeals.
· Determines whether to return, deny or pay claims following organizational policies and procedures.
Responsibilities:
· Reviews claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed.
· Researches to identifying underlying causes, and determine ways to prevent and correct such causes. Identifies and reports potential fraud and abuse situations.
· Researches and responds to complex customer inquiries, ensuring that contract standards and objectives for timeliness, productivity and quality are met.
· Handles situations that require adaptation of response or extensive research.
· Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
· Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes.
· Ensures claims are processing according to established quality and production standards.
· Provide feedback to management regarding customer issues. Maintain accurate records concerning issues.
· Follow through on complaints until resolved or report to management as needed.
· Maintain knowledge of procedures and policies. Assist with process improvements by recommending improvements in procedures and policies.
· Assists in training claims customer service representatives .
Experience:
· 3 years of customer service experience, including 1 year of claims or appeals processing experience .
Skills:
· Good verbal and written communication skills.
· Strong customer service skills.
· Good spelling, punctuation, and grammar skills.
· Basic business math abilities.
· Ability to handle confidential or sensitive information with discretion .
Education:
High School Diploma or equivalent.
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