About The Role:

Responsibilities:

• Respond to phone call requests for benefits by evaluating and determining coverage for benefits based on the member’s plan/client’s benefit plan.
• Respond to phone call inquiries regarding the processing of a claim.
• Research policy information and membership records to resolve issues.
• Maintain quality and production standards as defined by client contract and/or management determination of need.
• Manage time adequately to ensure proper turn-round for all tasks such as customer service requests, follow-up, and audit feedback.
• Work with teammates and supervisors to ensure the needs of the client are met.
• Assist in development of process improvement initiatives.
• May also process claims or adjustments

Accountabilities:

• Successfully completes all training programs as required.
• Acts in accordance with all HIPAA Privacy and Security guidelines to ensure confidential handling of protected health information.
• Execute prompt analytical decision making/research with specific attention to detail.
• Comply with State laws, policy and company procedures.
• Utilize specified phone call production tracking and reporting procedures.
• Adhere to strict attendance and tardiness policies.

Education & Experience:

• High school diploma or GED
• One year of claims adjudication/customer service experience or equivalent experience.

Language Requirements:

• Read and comprehend instructions, discussion, correspondence and memos in English.
• Ability to hold a conversation and communicate ideas in an understandable manner.
• Preferred medical terminology and medical claims coding knowledge.

Physical Requirements:

• Light repetitive movement of digits.
• Taking calls and talking clearly on a headset.
• Sitting 80% of time at a work station keying and viewing a computer screen.
• Walking, bending and reaching intermittently.

Other Requirements:

• Must be able to maintain confidentiality.
• Must have ability to speak clearly on a headset.
• Must be detailed oriented.
• Must have the ability to stay focused.
• Must have basic math skills.
• Must have reading comprehension skills to read and apply the provisions of specific plan documents.
• Must be able to key a minimum of 7,500 kph at 98% accuracy level.
• Must have the ability to work in a windows environment on a PC.
• Must have the ability to talk and type simultaneously.
• Must have the ability to make quick, sound judgments.
• Must be available for non-traditional hours due to shift schedule.