Provide prompt, accurate, thorough and courteous responses to all customer inquiries
Handle situations which may require adaptation of response or extensive research
Identify incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines
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
Must be able to speak Spanish and English fluently
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

Bilingual Claims Customer Service Advocate II

Key skills