Claims Service Representative

Job Description Centers Plan for Healthy Living’s goal is to create the ultimate healthcare experience that provides our members, their families, healthcare decision makers, and general caregivers with the guidance and plans they need for healthy living. Individualized professional and personal growth is a primary focus at CPHL. With various teams to match the unique strengths of each individual, tiered roles to support advancement, and opportunities for cross‑training and education, CPHL is the place for a fulfilling long‑term career. Professionally handle incoming inquiries via telephone, email or fax from providers (i.e., physician offices, clinics, social day cares, home care agencies, DME suppliers) regarding claim decision and payments across all Centers Plan for Healthy Living (CPHL) product offerings. Thoroughly and efficiently gather claim information, assess and fulfill the caller’s needs and educate the caller where applicable regarding claim submission procedures. Focus on resolving issues on the first call; navigate through the appropriate computer system(s) to identify the current status of the issue. Adjust claim(s) as warranted based on discussion and review of the provider’s issue. Deliver all information and questions in a positive, conversational and compassionate manner to facilitate developing a relationship with the provider, while providing the best customer service experience possible. Warm transfer calls to other business units for further resolution of the callers issue while adhering to CPHL’s policies. Complete the documentation necessary to track provider issues and facilitate the reporting of overall trends. Prepares correspondence, maintains phone and contact logs, and documents call details as appropriate. Meet or exceed the performance goals established for the position in the areas of: efficiency, call quality, provider satisfaction, first call resolution and attendance. Continuously evaluate and identify opportunities to drive process improvements that positively impact providers. Maintains strong knowledge of CPHL products and the applicable state and federal regulations. Education and Experience HS Diploma. 2 years of college preferred. Equal Opportunity Centers Plan For Healthy Living is committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law and will not be denied employment. #J-18808-Ljbffr