Claims Customer Service Representative III

Partnership HealthPlan of California•Fairfield, CA

17h•$34 - $40•Onsite

About The Position

The primary duty of the CSR III is to routinely process CIFs and learn all CIF claim types within 18 months of accepting the position. This role involves researching, resolving, and communicating outcomes to providers on various claim-related issues, participating in provider meetings and focus groups, and adhering to established policies and regulations for accurate claim processing. The CSR III will also enter, process, and resolve claims in all formats, participate in special projects, and provide feedback for operational efficiency. Secondary duties include supporting CSR staff during high call volumes and, with authorization, adjusting specific claim types based on demonstrated proficiency.

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

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.
Participate in quarterly provider focus group meetings and in-services with Provider Relations staff.
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.
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.