Medical Claims Customer Service Representative
Job Summary
The role involves examining, researching, and making decisions on telephone and written inquiries. Responsibilities include interpreting contract benefits according to claims processing guidelines, communicating issues related to the claims processing system, and utilizing information about benefits, coverage, and policies. The position requires maintaining professional external contacts with policyholders, service providers, agents, attorneys, and other carriers, as well as internal contacts with peers, management, and support areas.
Essential Duties & Responsibilities
- Interpret Contract Benefits: Accurately explain contract benefits to policyholders, agents, and providers in a professional manner.
- Claim Status Updates: Provide claim status information to policyholders or providers positively and professionally.
- Refund Requests: Send and follow up on refund request letters.
- Customer Correspondence: Produce correspondence to customers.
- Answering Calls: Answer incoming calls as required, professionally and promptly.
- Outgoing Calls: Place outgoing calls to provide or obtain information as needed.
- Call Documentation: Document all calls in writing or online while in progress.
- Call Transfers: Transfer calls to other departments as needed to meet customer needs.
- Policy Documentation: Fully document policy files or imaging systems with all related materials for a clear audit trail.
- Training Participation: Actively participate in cross-training and group training sessions to enhance team efficiency and meet service standards.
- Open Communication: Communicate openly with supervisors, team leads, and team members to ensure accurate responses and avoid duplication of efforts.
Education/Experience
- Education: High School Diploma or GED equivalent.
- Experience: Minimum of one year of related experience in a fast-paced call center is required.
- Experience in medical/insurance and with Medicare Supplement is preferred.
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