Claims Customer Service Advocate II #26-11515

Duration: 03 Months. Credit check and C2 security clearance required; clearance process may take 6–8 weeks.

About the role

Onsite position with 6 weeks of onsite training. Core hours are 8 am – 5 pm; occasional mandatory overtime may be required. Call center operates 8 am – 7 pm; shift may change after training. Potential for conversion to full-time employment supporting Tricare East. Interviews will be conducted in-person/onsite.

Responsibilities

• Respond to customer inquiries, including non-routine requests that require deviation from standard scripts and procedures.
• Perform research to resolve inquiries and ensure effective customer relations through accurate, timely, and courteous responses via telephone, written, web, or walk-in channels.
• Handle complex situations that may require adaptation of response or extensive research.
• Review and adjudicate claims and/or non-medical appeals; determine whether to return, deny, or pay claims following organizational policies and procedures.
• Identify incorrectly processed claims and process adjustments and reprocessing actions according to department guidelines.
• Examine and process claims and/or non-medical appeals according to business/contract regulations, internal standards, and examining guidelines.
• Enter claims into the claim system after verifying correct coding of procedures and diagnosis codes; ensure claims process according to established quality and production standards.
• Identify complex complaints and inquiries that cannot be resolved following desk procedures and refer them to a lead or manager.
• Identify and report potential fraud and abuse situations.

Requirements

• 2 years of customer service experience including 1 year of claims or appeals processing, OR a Bachelor’s degree in lieu of work experience.
• Good verbal and written communication skills.
• Strong customer service skills.
• Good spelling, punctuation, and grammar skills.
• Basic business math proficiency.
• Ability to handle confidential or sensitive information with discretion.
• Proficiency with Microsoft Office.
• High school diploma or equivalent.

About US Tech Solutions

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. Visit www.ustechsolutions.com for more information.