🪄 Skills: Communication SkillsCustomer serviceMicrosoft OfficeCritical thinkingData entryComputer skills
Requirements:
Familiarity with Microsoft Office products
Excellent computer skills using multiple screens and systems to achieve results
Experience in highly transactional call center environment
Excellent customer service and critical thinking
This is a fully-remote position.
Candidate must be able to work independently and be comfortable with virtual training and communication methods.
Secure, private home office location where PHI/PII information is not visible or overheard by others.
High speed internet access (100 mbps or higher) and consistent, reliable connection is required.
Home office location must be set up with a direct connection to the router (Wi-Fi is not allowed).
High School diploma, G.E.D. or equivalent experience
Responsibilities:
Answers questions and resolves issues based on phone calls/letters from providers.
Triages resulting rework to appropriate staff.
Provide excellent customer services for high volume inbound provider calls for the Individual and Family Plan Exchange team.
Extensive claims research on multiple platforms to assist providers with payment questions.
Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, provider self-service tools, etc.
Uses customer service threshold framework to make financial decisions to resolve provider issues.
Explains provider's rights and responsibilities in accordance with contract.
Processes claim referrals, new claim handoffs, nurse reviews, provider complaints, and provider grievance and appeals.
Educates & assists providers on our self-service options.
Assists providers with credentialing and re-credentialing and contracting questions and issues.
Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming provider correspondence and internal referrals.
Performs review of member and provider claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible.