Responsible for responding to customer inquiries.
Perform research as needed to resolve inquiries.
Review and adjudicate claims and/or non-medical appeals.
Determine whether to return, deny or pay claims following organizational policies and procedures.
Ensure effective customer relations by responding accurately, timely, and courteously to inquiries.
Handle situations which may require adaptation of response or extensive research.
Identify incorrectly processed claims and process adjustments and reprocessing actions.
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 these to a lead or manager for resolution.
Identify and report potential fraud and abuse situations.

High School Diploma or equivalent
2 years of customer service experience including 1 year of claims or appeals processing experience OR Bachelor's Degree in lieu of work experience
Good verbal and written communication skills
Strong customer service skills
Good spelling, punctuation and grammar skills
Basic business math proficiency
Ability to handle confidential or sensitive information with discretion
Microsoft office

Claims Customer Service Advocate II

Key skills