Claims/Customer Service Rep

Claims/Customer Service Representative

The Claims/Customer Service Rep works with Reinsurance Carriers in filing for reimbursement for groups that have claimants that have gone over the Specific Stop Loss deductible. The Stop Loss Analyst also works with The Health Plan's Account Executives, Claims Team, Financial and Eligibility Teams in order to obtain information needed for the Reinsurance Carrier to reimburse funds to the group. The Claims/Customer Service Rep runs monthly reporting to send out to stop loss carriers, reviews reports to see if claims have exceeded the specific deductible and files any claims over the deductible with the stop loss carrier for reimbursement to the Client. The Claims/Customer Service Rep reviews monthly aggregate reports to see if Monthly Aggregate Accommodation needs to be filed and will file as required. The Claims/Customer Service Rep also reviews Level Funding stop loss reporting submitted by finance to determine if a reimbursement request needs to be filed and will file as required.

Required:

1. High School graduate or equivalent
2. Motivated and works independently
3. Detail oriented with good problem solving skills
4. Ability to prioritize and meet deadlines
5. Maintains confidentiality
6. Proficient in Microsoft Office products (Word, Excel)
7. Easily adapts to changes in work requirements

Desired:

1. Previous experience with claims processing and/or call center
2. Knowledge of stop loss
3. Two (2) years of experience in a claims processing environment with experience in all claim types
4. Familiar with client reports, Member EOB's Databytes (BI reporting) and assessing with accuracy and validity of report data

Responsibilities:

1. Maintain a positive working relationship with others
2. Communicate with internal and external customers in a timely, professional and friendly manner
3. Determine claims potentially eligible for filing
4. Demonstrate the proper sense of urgency needed for obtaining all information for filing or preparing to file stop loss claims
5. Communicate with Account Executives to obtain information from the Client required by the stop loss carrier
6. Files stop loss claims in an accurate, complete and timely manner
7. Run and/or prove stop loss reporting accurately and timely including both internally and externally
8. Works with stop loss carriers, Account Executives, Claims Team, Financial and Eligibility Departments to resolve issues at the root cause
9. Records and communicates all information clearly and accurately
10. Keep all member's protected health information (PHI) confidential

8:00am - 5:00pm 40

The Health Plan of West Virginia Inc