Claims Customer Service Representative III

Partnership HealthPlan of California•Fairfield, CA

10h•$33 - $39

About The Position

Primary duty of the CSR III is to routinely process CIFs. They will be responsible to learn all CIF claim types within 18 months of accepting position. Responsibilities 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 CIF 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. SECONDARY DUTIES AND RESPONSIBILITIES To provide support to CSR staff when call volume requires additional personnel. At the Supervisor’s discretion and Manager’s approval, a CSR III will be authorized to adjust their CIF’d claims. This authorization will be limited in scope to only those claim types they have demonstrated proficiency in and are consistently meeting both their quality and production goals.

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 and 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.
Ability to move, carry, or lift objects of varying size, weighing up to 5 lbs.
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

Routinely process CIFs
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 CIF 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.
Provide support to CSR staff when call volume requires additional personnel.
Adjust their CIF’d claims.