Claims Account Representative

Job Description

Job Description

SUMMARY: Provides excellent customer service to non-emergency Medicaid and MCO transportation providers. Answers calls regarding existing claims status, including handling tasks associated with those claims. Monitors timely receipt of information to contractors/providers. Ensures complete and sound claim settlements and investigations when necessary. Examines records and ensures that transportation providers are paid according to the contractual terms. Maintains the accuracy and confidentiality of data, records, and files. Provides customers/providers with exceptional quality and efficient customer service.

ESSENTIAL FUNCTIONS

• Answers calls regarding existing claims status
• Provides first call resolution; working with appropriate internal/external resources, completing the necessary follow-up, and ensuring closure of the inquiry
• Answers incoming requests in a friendly manner, responds to routine questions; inputs and/or logs information received into the computer equipment; directs requests to the appropriate department or agency for further action.
• Resolves claims problems by clarifying issues, researching and exploring answers and alternative solutions, implementing solutions, and escalating unresolved problems.
• Listens and communicates clearly, professionally and empathetically
• Works from established procedures, scripts and job aids to handle multiple applications while assisting customers on the phone
• Escalates problems or inquiries as needed
• Maintains quality, accuracy and professionalism in a fast-paced environment
• Ability to multi-task and adapt to changing environment
• Processes claims
• Able to handle complex claims
• Must have good understanding of contracts, claims processing, and policies
• Excellent knowledge of the organization
• Claims related project work
• Other duties as assigned

REQUIRED SKILLS AND ABILITIES

• Professional telephone etiquette including excellent verbal communication skills and use of proper grammar
• Ability to process information and react quickly and appropriately
• Strong work ethic and self-starter, able to effectively manage multiple priorities and adapt to change within a fast-paced business environment
• Excellent listening skills and the ability to ask probing questions, understand concerns, and overcome objections
• Prior customer service experience
• Must adhere to HIPAA standards
• Displays written and verbal communication skills with executive management and staff, and is able to follow written and oral instructions. 
• Ability to process, formulate and modify policies; train and direct staff.
• Possesses good organizational skills, ability to focus on assigned tasks
• Able to work collaboratively, diplomatically, and with integrity in identifying and resolving problems. 
• Displays knowledge of ethical principles and compliance issues in an accounting setting. 
• Ability to foster positive working relationships across all departments
• Able to handle highly confidential and sensitive information
• Highly organized, displays strong attention to detail and accuracy
• Ability to multi-task giving attention to deadlines
• Intermediate level proficiency in Microsoft Word and Excel
• Ability to work extended hours when workload necessitates

Professional appearance QUALIFICATION

• High School diploma.
• Minimum of 2 years leadership experience
• Minimum of 3 years of recent (within the last 5 years) claims processing experience
• Healthcare, Medicaid and MCO, claims experience a plus