Customer Service Specialist
: Job Details :

Duration: 6+ months (Possible contract to hire)

Job Description:

· Imp notes: Monday-Friday 7:30-4:00.

· A typical day would like in this role: Have claims workload for day to work from and will be assigned priority claims, will also work info buckets as needed.

· Previous claims processing experience//familiarity with excel spreadsheets/word suite.

· Skill sets/qualities: Claims processing experience/customer service.

· Provides prompt, accurate, thorough and courteous responses to all complex customer inquiries.

· Inquiries are typically non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries.

· Reviews and adjudicates complex or specialty claims and/or non-medical appeals.

· Determines whether to return, deny or pay claims following organizational policies and procedures.

Responsibilities:

· Reviews claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed.

· Researches to identifying underlying causes, and determine ways to prevent and correct such causes. Identifies and reports potential fraud and abuse situations.

· Researches and responds to complex customer inquiries, ensuring that contract standards and objectives for timeliness, productivity and quality are met.

· Handles situations that require adaptation of response or extensive research.

· 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.

· Provide feedback to management regarding customer issues. Maintain accurate records concerning issues.

· Follow through on complaints until resolved or report to management as needed.

· Maintain knowledge of procedures and policies. Assist with process improvements by recommending improvements in procedures and policies.

· Assists in training claims customer service representatives .

Experience:

· 3 years of customer service experience, including 1 year of claims or appeals processing experience .

Skills:

· Good verbal and written communication skills.

· Strong customer service skills.

· Good spelling, punctuation, and grammar skills.

· Basic business math abilities.

· Ability to handle confidential or sensitive information with discretion .

Education:

High School Diploma or equivalent.