Customer Service Specialist

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Job description

Duration: 6+ months (Possible contract to hire)

Job Description:

Imp notes: Monday-Friday 7:30-4:00.

A typical day would like in this role: Have claims workload for day to work from and will be assigned priority claims, will also work info buckets as needed.

Previous claims processing experience familiarity with excel spreadsheets/word suite.

Skill sets/qualities: Claims processing experience/customer service.

Provides prompt, accurate, thorough and courteous responses to all complex customer inquiries.

Inquiries are typically non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries.

Reviews and adjudicates complex or specialty claims and/or non-medical appeals.

Determines whether to return, deny or pay claims following organizational policies and procedures.

Responsibilities:

Reviews claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed.

Researches to identifying underlying causes, and determine ways to prevent and correct such causes. Identifies and reports potential fraud and abuse situations.

Researches and responds to complex customer inquiries, ensuring that contract standards and objectives for timeliness, productivity and quality are met.

Handles situations that require adaptation of response or extensive research.

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.

Provide feedback to management regarding customer issues. Maintain accurate records concerning issues.

Follow through on complaints until resolved or report to management as needed.

Maintain knowledge of procedures and policies. Assist with process improvements by recommending improvements in procedures and policies.

Assists in training claims customer service representatives .

Experience:

3 years of customer service experience, including 1 year of claims or appeals processing experience .

Skills:

Good verbal and written communication skills.

Strong customer service skills.

Good spelling, punctuation, and grammar skills.

Basic business math abilities.

Ability to handle confidential or sensitive information with discretion .

Education:

High School Diploma or equivalent.

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