Ensures 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.
Ensures claims are processing according to established quality and production standards.
Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers 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 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.
Experience researching and processing Coordination of Benefits Claims.

Claims Customer Service Advocate II

Key skills