Claims Customer Service Representative

INNOVATIVE INTEGRATED HEALTH•Fresno, CA

17d•$19 - $23•Onsite

About The Position

The Claims Customer Service Representative (CCSR) serves as a liaison between Innovative Integrated Health, Inc. and external healthcare providers who submit claims. The CCSR responds to provider inquiries and works to resolve claims-related issues while maintaining professionalism, confidentiality, accuracy, and efficiency. The role requires strong judgment and communication skills, the ability to manage multiple priorities in a fast-paced environment, and compliance with regulatory and privacy standards, including HIPAA. PACE by IIH provides personalized, comprehensive care plans and community support to help senior participants age at home with dignity. The organization uses an interdisciplinary, participant-centered model to promote quality of life and independence. The position is based at the Fresno center. Work is generally performed indoors in a well-lit, well-ventilated, heated, and air-conditioned environment. A high school diploma or GED is required, as is at least two years of work experience. The role also has physical demands, including lifting and frequent movement, and requires the ability to communicate verbally in English.

Requirements

At least two years of work experience.
High school diploma or GED.
Proficiency in Microsoft Office, including Excel, Outlook, and Word.
Familiarity with medical billing terminology, including ICD-10, CPT, HCPCS, and Explanation of Payments (EOPs).
Strong oral and written communication skills.
Ability to multitask and remain detail-oriented under pressure.
Strong interpersonal and problem-solving skills and a collaborative mindset.
Ability to learn and apply regulatory requirements quickly.
Ability to access all areas of the center throughout the workday.
Ability to lift at least 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; assistance from another employee is required when lifting or transferring objects over 50 pounds.
Ability to perform constant hand grasping and finger dexterity; frequent sitting, standing, walking, and repetitive leg and arm movements; and occasional bending, forward and overhead reaching, squatting, and kneeling.
Ability to communicate verbally with excellent comprehension of English.
Medical clearance for communicable diseases and up-to-date immunizations before engaging in direct participant contact.

Nice To Haves

Knowledge of claims processing software.
At least one year of experience working in a healthcare call center.
Experience working remotely.

Responsibilities

Respond to provider inquiries about medical and dental claims by phone and email.
Research and resolve issues involving claim status, denials, and payment discrepancies.
Maintain current knowledge of benefit plans, claim adjudication guidelines, coding requirements, and HIPAA regulations.
Document interactions and claim actions accurately in the company system in accordance with compliance standards.
Maintain accurate records of interactions and claim resolutions.
Explain complex benefit details clearly and concisely to providers.
Collaborate with internal departments to resolve claims-related issues.
Recommend process improvements to enhance service delivery and the provider experience.
Provide empathetic and efficient service to providers.
Complete duties with a focus on quality, compliance, and provider satisfaction.
Maintain punctuality and professionalism and follow company policies and attendance requirements.
Attend and participate in audits, staff meetings, in-services, and other assigned projects.
Follow center practices, procedures, and policies, including assigned break times and attendance requirements.
Accept assigned duties cooperatively and perform other related duties as assigned.
Adjust work schedule as needed to meet operational demands.