Customer Service Representative/Service Advocate
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POST DATE 9/15/2016
END DATE 10/30/2016
JOB DESCRIPTIONSchedule is M-F 9:45a-6:15p
? Assist providers with the entry and update of requests for medical clearances
? Research, coordinate and resolve inquiries and claims exceptions
? Coordinate with other Provider Service areas to identify formal education opportunities
? Identify, document and monitor process improvements
? Research and triage claims and inquiries prior to forwarding to clinical nurse for review
? Data entry into Care Platform (e.g., authorizations and/or cases
? Distribute case work/census, etc. to clinical nurse
? Data entry of appeals
? Resolves grievances, appeals or disputes involving expressions of dissatisfaction, reimbursement, medical necessity, Claims Xtend, Utilization Management, and Fee for Service payments within regulatory timeframes for all lines of business with some exceptions.
? Ensures final determination with statement that supports determination is communicated to the member and/or the provider in required timelines.
? Send decision letters to members and providers
? Maintains Personal Health Information (PHI) confidentiality
The job title that typically fills this role is an Service Advocate IV - Clinical Support, Service Advocate V - Clinical Support, Associate IIIb - Appeals and Admin Support (HEDIS/STARS)
? High School diploma or equivalent
? 2+ years experience in health insurance, provider's office (handling medical coding, filing insurance claims or referrals) or a managed healthcare telephone service center
? Experience working with healthcare products including researching and resolving provider inquiries and working with provider contracts and networks
? Experience working with medical terminology, CPT-4 coding, ICD-9 coding and claims adjudication inquiry resolution processes and procedures
? Experience working with MS Word and Excel
? Successful performance on job related assessments
? Requires 9:45 a.m. to 6:15 p.m. shift coverage
? Ability to access and navigate through multiple system applications We are an equal employment opportunity employer and will consider all qualified candidates without regard to disability or protected veteran status.