Claims Customer Service Advocate II

About This Role

Respond to routine correspondence and telephone inquiries pertaining to claims or appeals, identify incorrectly processed claims, and perform adjustments and reprocessing actions to ensure compliance with contract standards.

Responsibilities

• Respond to written and/or telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are met
• Accurately document inquiries
• Identify incorrectly processed claims and process adjustments and reprocessing actions according to department guidelines
• Examine and process claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines
• Enter claims into the claim system after verification of correct coding of procedures and diagnosis codes
• Ensure claims are processing according to established quality and production standards
• Identify complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refer them to a lead or manager for resolution
• Identify and promptly report and/or refer suspected fraudulent activities and system errors to the appropriate departments

Requirements

• High School Diploma or equivalent
• 1 year of experience in claims/appeals processing, customer service, or related support area OR Bachelor's degree
• Good Verbal and Written Communication Skills
• Strong Customer Service Skills
• Good Spelling, Punctuation and Grammar Skills
• Basic Business Math Proficiency
• Ability to Manage Confidential or Sensitive Information with Discretion
• Microsoft Office

Qualifications

• A High School Diploma or equivalent
• 1-year of experience including 1-year claims/appeals processing, customer service, or other related support area OR bachelor’s degree in lieu of work experience.

Nice to Have

• Associate degree
• 2 years of claims processing or call center experience
• Knowledge of word processing, spreadsheet, and database software

Skills

* Required skills

Benefits