Customer Service Rep

Responsibilities:

1. Respond to phone call requests for benefits by evaluating and determining coverage for benefits based on the member’s plan/client’s benefit plan.
2. Respond to phone call inquiries regarding the processing of a claim.
3. Researches policy information and membership records to resolve issues.
4. Maintain quality and production standards as defined by client contract and/or management determination of need.
5. Manage time adequately to ensure proper turn around for all tasks such as CUSTOMER SERVICE requests, follow-up, and audit feedback.
6. Work with teammates and supervisor to ensure the needs of the client are being met.
7. Assist in development of process improvement initiatives.
8. May also process claims or adjustments

Accountabilities:

1. Successfully completes all training programs as required.
2. Acts in accordance with all HIPAA Privacy and Security guidelines to ensure confidential handling of protected health information.
3. Execute prompt analytical decision making/research with specific attention to detail.
4. Comply with State laws, policy and company procedures.
5. Utilize specified phone call production tracking and reporting procedures.
6. Adhere to strict attendance and tardiness policies.

Education & Experience:

1. High school diploma or GED
2. One year of claims adjudication/CUSTOMER SERVICE experience or equivalent experience.

Language Requirements:

1. Read and comprehend instructions, discussion, correspondence and memos in English.
2. Ability to hold a conversation and communicate ideas in an understandable manner.
3. Preferred medical terminology and medical claims coding knowledge.

Physical Requirements:

1. Light repetitive movement of digits.
2. Taking call and talking clearly on a headset.
3. Stationary 80% of time at a work station keying and viewing a computer screen.
4. Moving, positioning, and reaching intermittently.

Other Requirements:

1. Must be able to maintain confidentiality.
2. Must have ability to speak clearly on a headset.
3. Must be detailed oriented.
4. Must have ability to stay focused.
5. Must have basic math skills.
6. Must have reading comprehension skills to read and apply the provisions of specific plan documents.
7. Must be able to key a minimum of 7,500 kph at 98% accuracy level.
8. Must have the ability to work in a windows environment on a PC.
9. Must have the ability to talk and type simultaneously.
10. Must have the ability to make quick, sound judgments.
11. Must be available for non-traditional hours due to shift schedule.