Provider Claims Service Representative

Responsibilities

• Under the general direction of the Operations Call Center Supervisor, responsible for responding in a timely, professional and courteous manner to all customer needs.
• This includes provider phone calls or correspondence regarding benefit, eligibility, and other provider issues.
• Reviews and adjudicates claims based on provider and health plan contractual agreements and claims processing guidelines.
• Serves as a Subject Matter Expert.
• Conducts cross training to staff as required.
• Demonstrates solid knowledge of Provider Service/Claim systems, functions and team process.
• Demonstrates superior skill in dealing with provider issues/inquiries, team members, and co-workers.
• Suspends claims requiring additional information and/or special handling; initiates action to obtain required information.
• Forwards claims requiring external department intervention to the appropriate department or person.
• Monitors outstanding inquiries and works with management staff to identify and resolve areas of non-compliance.
• Reviews and verifies quality audit reports.
• Reconciles audit discrepancies, corrects in system and make appropriate changes to avoid recurrence.
• Maintains thorough knowledge of claims process systems, its databases and subsystems.
• Responds to and resolves provider and health plan claim inquiries.
• Monitors and tracks aged, pended, and open reports to maintain timeliness in claims processing.
• Inputs claims into the system for appropriate tracking and processing.
• Documents file, as appropriate, to support payment decision.
• Actively participates in user acceptance testing functions, such as test script development, testing and documentation of test results.

Education/Experience

• Minimum 4 years’ experience in claims and/or call center required.
• High School/GED required.
• Associate degree preferred; minimum 45 wpm typing preferred.
• Healthcare or Managed Care experience preferred.
• Working knowledge of PC apps in a windows based environment.

Training Information

• Training is conducted onsite Monday through Friday from 8:30 AM – 5:00 PM and lasts approximately 6–7 weeks (maximum).
• During this period, you are required to be fully available and onsite for the entire duration of training.
• Upon successful completion of training, the role will transition to a remote work environment.
• However, you may be required to report to a business office for mandatory meetings and/or technical support related to remote work.

Work Schedule

• Our Contact Center operates 24 hours a day, and this position requires flexibility to work shifts between 7:00 AM – 7:00 PM.
• Start times will vary, typically ranging from 7:00 AM to 10:30 AM, and are assigned based on business needs (example shift: 10:30 AM – 7:00 PM).
• Your permanent schedule will be assigned toward the end of training and will remain consistent based on operational needs.