Claims Customer Service Representative I

Partnership HealthPlan of California•Fairfield, CA

1d•$30 - $35•Onsite

About The Position

This role is responsible for researching and resolving provider telephone and written inquiries within established timeframes. The Claims Customer Service Representative I will accurately screen claims, participate in provider meetings and projects, and support escalated calls or more complex inquiries requiring additional skills. Additionally, this position provides support to CSR staff during high call volume periods and routinely processes CIFs as part of their daily workload.

Requirements

High school diploma or equivalent.
Minimum one (1) year of prior claims processing experience in an automated claim environment; or equivalent combination of education and experience.
Knowledge of CPT, HCPC procedure coding, and ICD-9 diagnostic coding.
Knowledge of medical terminology.
Ability to access coding reference guides for accurate information.
Typing speed 30 wpm.
Proficient use of 10-key calculator.
Effective written and oral communication skills.
Ability to effectively exercise good judgment within scope of authority and handle sensitive issues with tact and diplomacy.
Good organization skills.
Ability to accurately complete tasks within established times.
Ability to use a computer keyboard.
Provide the highest possible level of service to clients.
Promote teamwork and cooperative effort among employees.
Maintain safe practices.
Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

Responsibilities

Respond to provider telephone inquiries; research policy issues, analyze EOPs and claim history, recommend resolution to the issues, implement resolution once approved and communicate outcome to providers within established timeframes.
Research, resolve, and communicate outcome to providers on CIFs, claim tracers, and general claim correspondence within established timeframes.
Participate in provider meetings to resolve claim issues. Along with Provider Relations staff, participate in quarterly provider focus group meetings and in-services.
Follow established Partnership policies and procedures, Partnership claims operating instruction memorandums, EDS provider manual guidelines, and Title 22 regulations when resolving claims and claim issues.
Complete claim processing accurately within established production standards.
Enter, process, and resolve claims from all Partnership claim types and in any form (paper or electronic) within established standards. This will include electronic and paper crossover claims, pended claims, and claims which require manual pricing.
Participate in special projects and assignments as required.
Recognize and give feedback to management on procedure changes that would result in more efficient operations.
Record daily production statistics and related activities on appropriate reports; turn all logs and reports in to Claims Customer Service Supervisor.
Participate in resolution of CIFs as required.