Healthcare Claims Representative
What You'll Be Doing:
This position is responsible for immediate responses to incoming provider calls regarding claims issues in a call center environment, as well as reprocessing claims as identified through incoming phone calls or submitted by provider relations staff.
1. Investigates and responds in a timely manner to incoming provider calls and correspondence maintaining excellent relationships with the provider community.
2. Identifies systematic and procedural issues resulting in claims processing errors and initiating action to resolve those issues. Documents calls, problems, and resolutions for future reference.
3. Maintains knowledge of provider contracts, plan policies and coverages, claims processing guidelines and systems, and an overall understanding of operational workflows and processes.
4. Identifies, reverses, and processes adjustments to claims processed in error.
5. Documents all findings and actions taken as a result of provider inquiry.
6. Communicates to providers plan policies, coverage, and procedures.
7. Interacts with other departments to obtain prompt and accurate resolutions to issues.
8. Assists in providing quality improvement feedback regarding systems, procedures, policies and performance. Communicated to claims processing management findings of errors and provides appropriate documentation.
9. Assists with departmental projects when needed and contributes to completion of projects by a given deadline.
10. Maintains strict confidentiality of patient information, financial information, and volume/workflow information.
11. Demonstrates a high degree of ownership and accountability for the resolution of provider concerns.
12. Perform other duties and projects as assigned.
Working hours: 8 AM - 6 PM
Key Competencies/Success Factors:
Lives the values: Integrity, Community, Collaboration and Stewardship, as defined in the performance appraisal.
Excellent customer service and interpersonal skills.
Proficient experience using Outlook, Word, Excel and PowerPoint in a Windows operating system.
Must be detail oriented.
Ability to adapt to fluctuating situations and perform work of a detailed nature, avoiding errors.
Ability to multi-task calls and correspondence on a daily basis.
Proficient skills in maneuvering through multiple systems on a daily basis.
This position primarily works in a climate controlled based setting. The noise level and the work environment are moderately quiet.
Finishing Touches (Preferred):
- Bachelor's degree preferred.
1 year managed care or related experience preferred.
Healthcare customer service experience preferred. Customer service experience preferred.
3-5 years of experience as a Provider Claims Service Representative or comparable experience preferred.
Medical claims coding certification preferred.
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