Claims Customer Service Advocate I

Claims Processor

Responsible for responding to routine inquiries. Identifies incorrectly processed claims and completes adjustments and related reprocessing actions. Reviews and adjudicates claims and/or non-medical appeals. Determines whether to return, deny or pay claims following organizational policies and procedures.

40% Responds to written and/or telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are met. Accurately documents inquiries. Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.

40% 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.

20% Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution. Identifies and promptly reports and/or refers suspected fraudulent activities and system errors to the appropriate departments.

Required Skills and Abilities: Good verbal and written communication skills. Strong customer service skills. Good spelling, punctuation and grammar skills. Basic business math proficiency. Ability to handle confidential or sensitive information with discretion.

Required Software and Other Tools: Microsoft Office.

Work Environment: Typical Office Environment.

Required Education: High School Diploma or equivalent.

Required Work Experience: 1 year of experience in a claims/appeals processing, customer service, or other related support area OR Bachelor's Degree in lieu of work experience.