Claims Customer Service Representative

Primarily responsible for the customer service process associated with workers compensation claims which includes servicing customers who contact us via the ACD phone line and supporting the claims management process for all claims teams across the Enterprise. Acts as a back up to the claims intake process. Acts as a backup to the Service Center Business Development and Provider Relations teams on the ACD phone line.

PRIMARY RESPONSIBILITIES:

• Supports the customer service work and processes for the Enterprise claims teams as well as the Subrogation Teams.

• Answers claim inquiries from policyholders, agents, injured workers, attorneys, pharmacies, medical providers for multiple jurisdictions for the Enterprise claims teams. Provides verification of claim status for multiple jurisdictions using multiple technology sources.

• Performs all facets of IME’s, AME’s, DDE’s, QME’s and any other independent type evaluation needed for the claim file.

• Provides backup as needed to Claims Document Analysts to review and analyze incoming documents and assign the appropriate document sub type to them.

• Reviews each document and adds pertinent information to the document keywords and to appropriate data fields in the claim system.

• Re-indexes and appropriately routes documents that have been assigned an improper document type or have been attached to an incorrect claim.

• Assists with the resolution of FROI errors.

• Adds legal matters and pertinent litigation information to the claim system upon receipt of legal documents.

• Reviews, researches, and properly routes all unidentified claims mail for all brands within the Enterprise.

• Provides backup to the Claims Processing Associates for review, research, and proper routing of priority unidentified claims mail for all brands within the Enterprise.

• Processes Claims Subpoenas. Performs all facets of the following referrals: Utilization review, Medical Management, Vocational Rehabilitation, Litigation, and all other Vendor Referrals as requested.

• Participates in projects to improve processing and workflow.

• Provides PPO, MPN, HCN provider names and/or general program information to customers

• Updates claim system with vital information changes.

• Updates document management system when claim number changes occur.

• Provides backup to intake for multi-state claims processing.

• Produces forms, memos, reports, information and letters as requested.

• Provides policyholders, agents, and others as requested with copies of first report of injuries.

• Corrects department and location information on loss runs as requested.

• Inputs data into legal billing system.

• Organizes file materials in date order to be provided to various attorneys and vendors either via the vendor portal or another delivery method.

• Assigns services requests to TPA and other vendors via the vendor portal.

• Communicates with appropriate state WC division to discuss various issues.

• Makes contact with employer and/or injured worker if necessary to obtain information.

• May participate with training of team members.

• Serves as a resource with creation of documentation of general and state specific procedures as it relates to this position.

• Communicates and collaborates with team members to ensure the appropriate and timely handling of claims.

• Performs all tasks specified for multiple jurisdictions for all Enterprise Claims Teams.

• Inputs notes into medical bill review web based system for disputes/denials.

• Manually produces claim welcome packets as requested.

• Researches outstanding checks for escheatment process and mails form letter to check recipient if applicable.

• Forwards travel documents back to sender requesting additional information.

• Types, photocopies, faxes as necessary.

This description identifies the responsibilities typically associated with the performance of the job. The percentage of time in any responsibility may vary between positions. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

A. EDUCATION REQUIRED :

High School Diploma or G.E.D. required. Minimum of an Associates degree in insurance or related field, but a combination of education and experience may be considered in lieu of formal education.

B. EXPERIENCE REQUIRED:

Minimum of three years general office experience including a minimum of one year in workers’ compensation insurance. Prior experience answering inquires over the phone at AF Group or equivalent relevant internal experience that would provide the required skills, knowledge and abilities. Relevant customer service experience exchanging information and answering basic inquiries over the phone is required

OR

Minimum of four years of general office experience. Two years of customer service experience answering inquiries over the phone in an insurance organization. Prior equivalent relevant experience that would provide the required skills, knowledge and abilities may be considered.

C. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Basic knowledge of insurance claims excellent customer service skills.

• Excellent telephone etiquette.

• Excellent verbal and written communication skills.

• Excellent organizational skills and ability to prioritize work.

• Ability to manage multiple priorities and meet established deadlines.

• Knowledge of multi functional telephone system.

• Ability to research information in multiple systems.

• Ability to obtain pertinent and thorough information from customers.

• Ability to be an independent thinker to solve issues.

• Ability to work effectively with various business units.

• Excellent organizational skills and ability to prioritize work to meet established deadlines.

• Knowledge of computers and spreadsheet software.

• Ability to proofread correspondence for accuracy of spelling, grammar, punctuation, and format.

• Knowledge of word processing software with data entry ability of 40 w.p.m.

• Ability to verify data for accuracy.

• Knowledge of medical terminology.

• Knowledge of legal terminology.

• Ability to multi-task, i.e. interacts on telephone while entering data.

• Ability to train and coach others to perform the core responsibilities.

• Ability to work varied hours/days/shifts.

• Ability to assist with the creation of procedural documentation and workflows.
  

D. ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED:

• Insurance Institute of America (IIA) Certification

• Experience handling claims in multiple states.

• Spanish fluency (Premium will apply upon completion of Spanish testing requirements.)

• Experience on an ACD telephone system

• Experience using a document management system with workflows

• Knowledge of CPT, ICD9 and 10, and drug codes
  

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards.

REQUIRED TESTING:

Basic Word, Basic Excel, and Basic Windows. Reading Comprehension, Proofreading, Typing 40 wpm