Claims Customer Service Representative I

Integrity•Clearwater, FL

About The Position

The Claims Customer Service Representative I examines, researches, and makes decisions needed to adjudicate telephone and written inquiries. The role interprets contract benefits in accordance with claims processing guidelines and communicates issues related to the claims processing system to the appropriate team. It involves using information about benefits, contract coverage, and policy decisions, and maintaining positive, professional contact with policyholders, service providers, agents, attorneys, other carriers, colleagues, management, and support teams.

Requirements

High school diploma or GED equivalent.
0–2 years of experience in a fast-paced call center or relevant experience.

Nice To Haves

Experience in medical or insurance.
Experience with Medicare Supplement.

Responsibilities

Accurately interpret contract benefits and communicate details to policyholders, agents, and providers in a positive, professional manner.
Provide clear and timely claim status updates to policyholders and providers.
Prepare, send, and follow up on refund request letters as necessary.
Create and deliver correspondence to customers as needed.
Answer incoming calls and place outbound calls to provide or obtain information, ensuring interactions are helpful, professional, and timely.
Document calls while in progress and fully update policy files or imaging systems to maintain a clear audit trail.
Transfer calls to appropriate departments to ensure customer needs are met efficiently.
Participate in cross-training and group training sessions to enhance team efficiency and uphold service standards.
Maintain open communication with supervisors, team leads, and colleagues to ensure accurate responses and prevent duplication of efforts.
Perform other duties as assigned to support the needs of the team.
Communicate problems relevant to the claims processing system to the appropriate team.