Customer Service Representative

Department Claims Job Title Customer Service Representative Summary: Responds to telephone inquiries from beneficiaries and providers. This is a beginning level Customer Service Representative working under the direct supervision of the Compliance/Claims Manager. Duties and Responsibilities: Answer incoming phone calls from customers and identify the type of assistance the customer needs (i.e. benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits (EOBs) Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems. Own problem through to resolution on behalf of the customer in real time or through comprehensive and timely follow-up with the member Coordinates complete resolution of service issues by interfacing with other departments, including Eligibility, Benefits and Claims. Review and research incoming healthcare claims from members and providers(doctors, clinics, etc) by navigating multiple computer systems and platforms and verifies the data/information necessary for processing (e.g. pricing, prior authorizations, applicable benefits) Ensure that the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/certificates) Develop an understanding of the grievances and appeals process available to dissatisfied beneficiaries and providers. Communicate and collaborate with members and providers to resolve issues, using clear, simple language to ensure understanding Transfer calls to appropriate departments when necessary Performs other duties as assigned, in compliance with Health Source MSO policies and contractual requirements. Update all member claims and/or notes file of computer in a timely manner, using appropriate coding Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendance Generates, prints and mails appropriate letters to members or providers as needed in a timely manner with no errors Other duties as assigned by the Compliance or Claim Manager Job Requirements: Prefer 1 year experience in an office setting, call center setting or phone support role, but not required High school graduate or equivalent, with at least 1 year of customer service experience in the health care industry. Keyboarding skills needed. Demonstrated ability in using computer and Windows PC applications, which includes strong keyboard and navigation skills and learning new computer programs Ability to multi-task duties as well as the ability to understand multiple products and multiple levels of benefits within each product Ability to work regularly scheduled shifts within our hours of operation including the training period, where lunches and breaks are scheduled, with the flexibility to adjust daily schedule, and work over-time as needed EZ-cap System skill a plus