Customer Service Representative

Customer Service Representative

This position is responsible for the accurate and timely response to written claim inquiries received from providers. Incumbent provides support regarding the adjudication and adjustment of claims for the multiple lines of business. The incumbent works closely with Provider Relations, Medical Management, Member Services and the Claims Processing unit.

Key responsibilities include:

• Act as a key liaison and service representative for all written provider inquiries and problem resolution.
• Respond to all claim inquiries from provider sites personnel including physicians, clinical staff, and site administrators.
• Coordinate and track appropriate problem resolution activities with plan personnel in other departments (i.e., claims, utilization management)
• Manage and ensure appropriate follow-up and closure for all inquiries
• Respond to Provider Inquiries in writing; maintain accurate files
• Data Entry into the IMAX system.
• Perform claim adjustments to correct erroneous payments (overpayments/underpayments).
• Participate in Special Projects involving Claim Status Investigations.
• Resolve Member Bills referred from Member Services.

Required education, training, and professional experience:

• In-depth knowledge of Claims Processing protocols and payment schemes.
• Thorough knowledge of Plan Benefits.
• Proficiency in IMAX and TXEN.
• Customer Service Experience a plus.
• Must be able to handle irate providers in a professional manner.
• Excellent written/verbal communication skills.

Professional competencies:

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication