The Customer Service Representative I will answer and resolve provider telephone and written
inquiries within established time frames. This position will accurately screen correspondence,
perform research, refer to appropriate team as necessary, track follow-up to ensure completion,
document all interactions with providers, research and complete various tasks, as appropriate for
individual roles, such as claims review, provider dispute resolutions, provider surveys, provider
change forms and paper and electronic correspondence within established time frames, applying
appropriate program policies.
▪ Responds to provider telephone inquiries, researches policy issues, analyzes provider
concerns, recommends resolution to the issues, collaborates with other departments as
necessary and documents all provider communication and actions taken.
▪ Researches and communicates outcome to providers regarding inquiries and requests
within established time frames.
▪ Follows established Partnership policies and procedures, Partnership operating
instruction memorandums, EDS provider manual guidelines, and Title 22 regulations
when resolving claims or provider issues.
▪ Recognizes and gives feedback to management on procedure changes that would result in
more efficient operations.
▪ Records daily production statistics and related activities on appropriate reports; turns all
logs and reports in to Supervisor.
▪ Meets established production and call performance metrics as determined.
▪ Participates in special projects and assignments as required.
▪ Other duties as assigned.
Education and Experience | High school diploma or equivalent; Customer service experience and one (1) year of prior claims processing experience in an automated claim environment preferred; or equivalent combination of education and experience.
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Special Skills, Licenses and Certifications |
Knowledge of CPT, HCPC procedure coding, and ICD-10 diagnostic coding preferred but not required. Knowledge of medical terminology preferred. Ability to access coding reference guides for accurate information. Typing speed 30 wpm and proficient use of 10-key calculator.
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Performance Based Competencies |
Excellent written and oral communication skills. Ability to effectively exercise good judgment within scope of authority and handle sensitive issues with tact and diplomacy. Good organizational skills. Ability to accurately complete tasks within established time frames.
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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 25 lbs.
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All HealthPlan employees are expected to:
HIRING RANGE:
$28.94 - $34.00
IMPORTANT DISCLAIMER NOTICE
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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