Customer Service Representative

Role Overview

• Answering incoming telephone calls
• Providing eligibility and claim information to medical providers and members
• Reviewing and interpreting plan certificates to determine covered benefits and limitations/exclusions
• Investigating claim payment issues
• Researching PPO websites/database as required to determine if claims are received and processed by the PPO network
• Documenting telephone call reason and details in claim system
• Monitoring and answering voice mail
• Reviewing inventory tool for status requests from providers/members and responding professionally
• Initiating check inquiries (check tracers) from providers and members to determine if claim payment was received
• Understanding HIPAA Regulations and Requirements as it relates to Personal Health information
• Educating medical providers and members on new technology available to access plan information
• Using probing skills to identify customer questions/concerns regarding plan coverage/benefits and providing single call resolution
• Maintaining minimum call standards in accordance with company policy, industry standard & other applicable TPA or SLA agreements
• Completing special projects as required or requested by management

Requirements

• Effective time management skills
• Ability to function independently within established guidelines
• Excellent interpersonal, oral and written communication skills
• Intermediate skill level in Microsoft Office programs
• Problem/issue resolution capability
• Ability to handle multiple tasks, strong organizational/follow up skills
• Ability to work effectively in a fast paced team based environment
• Computer experience with related claims and business software