Claims Customer Service Advocate II

Position Title: Claims Customer Service Advocate II

Work Location: 29229

Assignment Duration: 3 months(CONTRACT TO HIRE)

Work Schedule: M-F 8:00-4:30.

Work Arrangement: Onsite

Position Summary:

• Responsible for responding to customer inquiries. Inquiries may be non-routine and require deviation from standard screens, scripts, and procedures.
• Performs research as needed to resolve inquiries. Reviews and adjudicates claims and/or non-medical appeals.

• Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries.
• Handles situations which may require adaptation of response or extensive research.
• Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
• Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
• Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes.
• Ensures claims are processing according to established quality and production standards.
• Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution.
• Identifies and reports potential fraud and abuse situations.

• Required Education: High School Diploma or equivalent
• Required Work Experience: 2 years of customer service experience, including 1 year claims or appeals processing OR Bachelor's Degree in lieu of work experience