The primary responsibility of the Claims Service Representative is to provide assistance to the TPA’s customer base. This is achieved by answering incoming calls from providers and insureds regarding clarification of benefits, status of claims, status of eligibility, and any other inquiry received.
- Answers all calls to the customer service unit using company guidelines and the utmost professionalism.
- Meets or exceeds customer service performance levels.
- Provides status of claims and eligibility.
- Provides benefit information to insureds/providers as permitted by the company.
- Verifies provider network information.
- Researches problem cases.
- Answers and provide resolution to all other inquiries from customers.
- Creates and updates telephone logs for all calls in company database.
- Works with Claims Examiners to manage specific claims inquiries per company guidelines.
- Answers incoming calls.
- Assists Auditor, Leads, and/or Examiners with any routine assignments or special projects.
- Performs other duties and special projects as assigned.
- Thorough knowledge of benefit plans offered through carriers.
- Outstanding interpersonal and communications skills are required to maintain effective relationships with clients, co-workers, carriers, vendors and others.
- Must be able to understand written and oral communications and interpret information written within the school brochures.
- Proficient computer skills.
- Working knowledge of the laws and regulations associated with HIPAA.
- Excellent customer service skills are a must
- Willingness to adhere to all principles of confidentiality
- Ability to show initiative, good judgment, and resourcefulness
- Ability to work independently and on a team
EDUCATION AND QUALIFICATIONS
- High School Diploma or its equivalent
- 1-2 years’ experience in Claims Service with preference given to health claims experience