Certified Call Center Claims Processor I

Certified Call Center Claims Processor I

The Certified Claims Call Center Processor I serves as a primary point of contact for provider offices and their authorized representatives, responding to inbound calls and electronic inquiries regarding professional and facility claims processing and adjudication.

This role combines customer service and certified claims processing responsibilities by independently resolving provider inquiries, researching claim issues, and adjudicating professional claims in accordance with company policy, contract language, coding guidelines, and applicable regulatory requirements.

The position is responsible for delivering timely, accurate, and professional claim resolutions while supporting positive provider relationships and maintaining departmental quality and production standards.

Essential Duties

1. Provider Communication & Support – Responds promptly and professionally to inbound provider calls, emails, and other inquiries regarding claim status, adjudication outcomes, benefits, pricing, coding, and payment determinations.
2. Claims Review & Resolution – Independently researches and resolves professional claim issues by reviewing claim history, coding, benefits, pricing logic, contract language, and applicable system edits to determine appropriate outcomes.
3. Claims Adjudication - Accurately adjudicates professional claims by applying CPT, HCPCS, ICD-10 coding guidelines, reimbursement methodologies, benefit plans, and regulatory requirements.
4. Documentation & Record Maintenance – Maintains accurate and detailed documentation of provider interactions, claim research, resolutions, and claim adjustments within the core claims system and applicable tracking tools.
5. Provider Education & Support – Explains claim outcomes, billing requirements, and processing guidelines to providers and their representatives while promoting positive provider relationships and understanding.

Job Duties

• Respond to a high volume of inbound provider calls and electronic inquiries while maintaining professionalism, accuracy, and customer service standards.
• Research and resolve provider inquiries by reviewing claim history, claim edits, payment determinations, authorization requirements, coding issues, eligibility information, and applicable policies.
• Process and adjudicate professional claims across multiple lines of business in accordance with established policies, procedures, coding guidelines, and benefit plans.
• Review and resolve claim edits, denials, adjustments, reconsiderations, disputes, and reprocessing requests by analyzing claim data, supporting documentation, and applicable policies to determine appropriate corrective action.
• Evaluate pending and problematic claims to identify root causes of processing issues, including billing errors, coding discrepancies, configuration issues, authorization concerns, coordination of benefits conflicts, eligibility issues, or missing information.
• Coordinate benefits by reviewing member eligibility, payer responsibility, and other insurance coverage information to ensure accurate application of coordination of benefits (COB) guidelines.
• Explain claim determinations, payment methodologies, denial reasons, and processing requirements clearly and professionally to provider offices and authorized representatives.
• Maintain accurate documentation of provider interactions, claim research, and claim resolutions within approved systems and tracking tools.
• Identify recurring claim issues, processing trends, or potential system concerns and escalate findings as appropriate.
• Communicate and collaborate effectively with providers, members, leadership, and internal departments to support timely and accurate issue resolution.
• Maintain compliance with HIPAA, PHI, claim routing procedures, inventory control standards, quality benchmarks, production expectations, and other applicable policies and regulatory requirements.
• Participate in a rotating call coverage schedule, including primary phone coverage and fill-in support during breaks, lunches, and periods of increased call volume, while assisting with claims processing as operational needs permit.
• Demonstrate flexibility and teamwork by assisting peers and supporting departmental workflows and operational priorities.
• Participate in ongoing training and continuing education to maintain coding certification and remain current on coding, reimbursement, regulatory, and industry changes.
• Maintain punctual, regular, and predictable attendance.
• Work collaboratively in a team environment and respectfully follow leadership direction.
• Perform other duties as assigned.

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Education

Associate degree (AA) from a two-year college or technical school required; or an equivalent combination of education and experience.

Experience

• Six months to one year of experience in healthcare claims processing, medical billing, provider services, customer service, or a related healthcare administrative role required.
• Experience reviewing, researching, and resolving claim-related issues preferred.
• Experience using healthcare claims processing systems preferred.
• EZ-CAP experience preferred.

Certificates, Licenses, and/or Registrations

Current coding certification from the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) required (e.g., CPC, CPC-P).

Bilingual Skills

Being bilingual in another language, including American Sign Language (ASL), is an invaluable skill that enhances our ability to deliver culturally responsive care. We strongly encourage you to apply if you are bilingual. All relevant experience can be listed in your resume to perform essential duties of the position including the following: lived, volunteer, professional, or a combination of experience and education.

Technical Skills

• Knowledge of medical terminology required.
• Working knowledge of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding systems required.
• Knowledge of CMS-1500, UB-04, and other healthcare claim forms required.
• Familiarity with healthcare claims processing and reimbursement practices.
• Familiarity with the healthcare industry.
• Knowledge of and ability to maintain compliance with HIPAA regulations.
• Proficient computer skills, including Microsoft Office Suite (Outlook, Word, Excel, and PowerPoint).
• Strong organizational and time-management skills.

Interpersonal Skills

• Demonstrates accountability and inspires trust and confidence in others.
• Works with initiative, energy, and effectiveness in a fast-paced environment.
• Collaborates effectively within a multidisciplinary and diverse team.
• Interacts positively with providers, customers, and internal stakeholders to resolve issues in a professional and courteous manner.
• Prioritizes and organizes work effectively while managing competing priorities.
• Manages time effectively to meet established productivity and quality standards.
• Adapts to change, learns quickly, and performs effectively in ambiguous situations.
• Maintains an attentive, empathetic, and service-oriented approach.
• Maintains a high degree of professionalism and confidentiality.
• Exercises sound judgment and takes initiative in completing responsibilities.

Language Skills

Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.

Mathematical Skills

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Computer Skills

Has advanced basic computer job skills including logging on to systems, ability to communicate by email, ability to compose documents, enter database information, create presentations, download forms, and preserve/backup important data

Reasoning Ability

Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to work with problems involving a few concrete variables in standardized situations.

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this job. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

The employee must occasionally lift and/or move up to 10 pounds. While performing the duties of this job, the employee is regularly required to sit