The CSR position interacts with customers to provide and process information in response to complex inquiries, concerns, and requests about health claims, coverage, benefits, and deductibles. Projects a professional company image and provides superior customer service by corresponding with Providers, Members, internal and external partners to proactively own the experience and resolve coverage issues.
Thoroughly and completely document all customer interactions.
Educates Members and Providers on eligibility, benefits, claims payment, and authorizations.
Provides direction on the usage and benefits of self-service tools.
Resolve claim benefit inquiries by researching and analyzing patient activity and determine appropriate action to be taken.
Adjusts claims data, when appropriate, to immediately resolve the inquiry and maintain first call resolution expectations.
Appropriately route inquiries to the necessary departments or individuals when resolution of the inquiry is beyond the span of control of this role and set follow ups.
Meet or exceed individual, department, and client specific goals. Assist providers by resolving coordination of benefits inquiries by analyzing patient activity (including enrollment, third party liability, and claims attachments).
Interpret and communicate accurate insurance coverage by having a comprehensive understanding of the process.
Meet or exceed individual and department goals.
Understands and adheres to all of the client’s administrative and contractual policies and procedures.
Takes ownership of the resolution and sets expectations for follow up.
Able to work a shift which may begin 8 am to 10 pm EST Monday – Friday.
Prior call center / medical experience helpful
Must have analytical/problem solving capabilities
Must be PC literate with 10-key proficient
Excellent oral and written communication skills