Provider Claims Service Representative

Responsibilities:    Under the general direction of the Operations Call Center Supervisor, responsible for responding in a timely, professional and courteous manner to all customer needs. This includes provider phone calls or correspondence regarding benefit, eligibility, and other provider issues.  Reviews and adjudicates claims based on provider and health plan contractual agreements and claims processing guidelines.  Serves as a Subject Matter Expert.  Conducts cross training to staff as required.  Demonstrates solid knowledge of Provider Service/Claim systems, functions and team process.  Demonstrates superior skill in dealing with provider issues/inquiries, team members, and co-workers.  
- Suspends claims requiring additional information and/or special handling; initiates action to obtain required information.
- Forwards claims requiring external department intervention to the appropriate department or person.
- Monitors outstanding inquiries and works with management staff to identify and resolve areas of non-compliance.
- Reviews and verifies quality audit reports.
- Reconciles audit discrepancies, corrects in system and make appropriate changes to avoid recurrence.
- Maintains thorough knowledge of claims process systems, its databases and subsystems.
- Responds to and resolves provider and health plan claim inquiries. Monitors and tracks aged, pended, and open reports to maintain timeliness in claims processing. Inputs claims into the system for appropriate tracking and processing.
- Documents file, as appropriate, to support payment decision.
- Serves as a Subject Matter Expert and conducts training as required.
- Conducts cross training to staff as required.
- Actively participates in user acceptance testing functions, such as test script development, testing and documentation of test results.

Education/Experience:​
- Minimum 4 years’ experience in claims and/or call center required.
- High School/GED required.
- Associate  degree preferred; minimum 45 wpm typing preferred.
- Healthcare or Managed Care experience preferred.
- Working knowledge of PC apps in a windows based environment.

Training Information:

- Training is conducted onsite Monday through Friday from 8:30 AM – 5:00 PM and lasts approximately 6–7 weeks (maximum) . During this period, you are required to be fully available and onsite for the entire duration of training .
- Upon successful completion of training, the role will transition to a remote work environment . However, you may be required to report to a business office for mandatory meetings and/or technical support related to remote work .

Work Schedule:

- Our Contact Center operates 24 hours a day , and this position requires flexibility to work shifts between 7:00 AM – 7:00 PM . Start times will vary, typically ranging from 7:00 AM to 10:30 AM , and are assigned based on business needs (example shift: 10:30 AM – 7:00 PM ).
- Your permanent schedule will be assigned toward the end of training and will remain consistent based on operational needs.