• Claims Customer Service Representative II

    Job Locations US-CA-Fairfield
    Job ID
  • Overview

    To research and resolve provider telephone and written inquiries within established timeframes, accurately screen claims, and participate in provider meetings and projects. Support for either escalated calls or to accept calls of a more complex nature requiring additional skills. To provide support to CSR staff when call volume requires additional personnel. Routinely process CIFs as part of their daily workload.


    • Respond to provider telephone inquiries; research policy issues, analyze EOPs and claim history, recommend resolution to the issues, implement resolution once approved and communicate outcome to providers within established timeframes.
    • 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 PHC policies and procedures, PHC 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 PHC 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.


    • Participate in special projects and assignments as required.
    • Will participate in resolution of CIFs as required.


    Education and Experience

    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.


    Special Skills, Licenses and Certifications

    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.


    Performance Based Competencies

    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.


    Work Environment And Physical Demands

    Ability to use a computer keyboard. More than 80% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up to 5 lbs.




    All HealthPlan employees are expected to:


    • Provide the highest possible level of service to clients;
    • Promote teamwork and cooperative effort among employees;
    • Maintain safe practices; and
    • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.




    The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.


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