Responsible for responding to customer inquiries
Performs research as needed to resolve inquiries
Reviews and adjudicates claims and/or non-medical appeals
Determines whether to return, deny or pay claims following organizational policies and procedures
Ensure effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries
Handles situations which may require adaptation of response or extensive research
Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines
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
Ensure claims are processed 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
Identifies and reports potential fraud and abuse situations

High School Diploma or equivalent
2 years of customer service experience including 1-year claims or appeals processing 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
Proficiency in Microsoft Office

Claims Customer Service Advocate II

Key skills