Claims Customer Service Advocate II

Duties

• Responsible for responding to customer inquiries. Inquiries may be non-routine and require deviation from standard screens, scripts, and procedures.
  • Performs research as needed to resolve inquiries.
  • Reviews and adjudicates claims and/or non-medical appeals.
  • Determines whether to return, deny or pay claims following organizational policies and procedures.
• Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries.
  • Handles situations which may require adaptation of response or extensive research.
  • Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
• 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.
• Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution.
  • Identifies and reports potential fraud and abuse situations.

Skills

• 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.
• Required Software and Other Tools: Microsoft Office.

Work Environment

Typical office environment.

Required Education

High School Diploma or equivalent

Required Work Experience

2 years of customer service experience including 1 year claims or appeals processing OR Bachelor's Degree in lieu of work experience.