Claims Customer Service Representative

Job Summary

The Claims Customer Service Representative (CCSR) serves as a critical liaison between Innovative Integrated Health, Inc. (Company) and external healthcare providers (Providers). The CCSR handles incoming inquiries from Providers who submit claims to the Company. The CCSR is expected to act with a high level of professionalism, confidentiality, and efficiency. The role requires excellent judgment, strong communication skills, and the ability to manage multiple priorities in a fast-paced environment. The CCSR is expected to demonstrate a high level of accuracy and attention to detail while upholding regulatory and privacy standards as mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Essential Job Functions

• Respond to Provider inquiries regarding medical and dental claims via phone and email.
• Research and resolve issues related to claims status, denials, and payment discrepancies.
• Maintain up-to-date knowledge of benefit plans, claim adjudication guidelines, coding requirements, and HIPAA regulations.
• Accurately document all interactions and claim actions in the Company system by compliance standards.
• Maintain accurate records of interactions and claim resolutions.
• Communicate complex benefit details in a clear and concise manner to Providers.
• Collaborate with internal departments to facilitate resolution of claims-related issues.
• Recommend process improvements to enhance service delivery and improve Provider experience.
• Provide empathetic and efficient service to when working with Providers.
• Ensure all duties are completed with a focus on quality, compliance, and Provider satisfaction.
• Maintain punctuality, professionalism, and adherence to company policies and attendance requirements.
• Attend and participate in audits, staff meetings, in-services, and other projects as assigned.

Qualifications

• Proficient in Microsoft Office (Excel, Outlook, Word); knowledge of claims processing software, preferred.
• Familiarity with medical billing terminology (ICD-10, CPT, HCPCS) and Explanation of Payments (EOPs).
• Strong oral and written communication skills.
• Proven ability to multi-task and remain detail-oriented under pressure.
• Strong interpersonal and problem-solving skills; collaborative mindset.
• Ability to learn and apply regulatory requirements quickly.

Experience

• Minimum of two (2) years work experience required.
• Minimum of one (1) year of experience working in a healthcare call center, preferred.
• Experience working remotely, preferred.

Education and Certification

• At a minimum a High School Diploma or GED is required.
• Is medically cleared for communicable diseases and has all immunizations up-to-date before engaging in direct participant contact.

Core Values

• CARE is central to what we do, prioritizing the well-being, dignity, and independence of our senior participants.
• COMPASSION in every interaction, ensuring kindness, empathy, and understanding guide our care.
• CULTURE that reflects the diverse backgrounds of those we serve and fosters a workplace where every team member feels supported, valued, and empowered to grow.
• COMMUNITY that fosters connection, belonging, and support for participants and their families.
• COMMITMENT to quality improvement, innovation, and delivering healthier outcomes.

Benefits

• 401(k)
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid sick time
• Paid time off
• Referral program
• Retail plan
• Vision insurance