Claims Customer Service Advocate II

Overview Responsibilities include responding to customer inquiries, reviewing and adjudicating claims and/or non-medical appeals, and ensuring claims processing aligns with organizational policies and procedures. The role involves research to resolve inquiries, determining whether to return, deny or pay claims, and identifying and addressing complex inquiries or potential fraud. Responsibilities Responsible for responding to customer inquiries. Inquiries may be non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries. Reviews and adjudicates claims and/or non-medical appeals. Determines whether to return, deny or pay claims following organizational policies and procedures. Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries. Handles situations which may require adaptation of response or extensive research. Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines. 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. 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 reports potential fraud and abuse situations. Duties Responsible for responding to customer inquiries. Inquiries may be non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries. Reviews and adjudicates claims and/or non-medical appeals. Determines whether to return, deny or pay claims following organizational policies and procedures. 45% Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries. Handles situations which may require adaptation of response or extensive research. Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines. 45% 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. 10% 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 reports potential fraud and abuse situations. Skills and Tools 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. Education and Experience Required Education: High School Diploma or equivalent Required Work Experience: 2 years of customer service experience including 1 year claims or appeals processing OR Bachelor's Degree in lieu of work experience. #J-18808-Ljbffr