Claims Customer Service Representative III
- Research, resolve, and communicate outcome to providers on CIFs, claim tracers, and general claim correspondence within established timeframes.
- Participate in provider meetings to resolve claim issues. Along with Provider Relations staff, participate in quarterly provider focus group meetings and in-services.
- Follow established PHC policies and procedures, PHC claims operating instruction memorandums, EDS provider manual guidelines, and Title 22 regulations when resolving claims and claim issues. Complete claim processing accurately within established production standards.
- Enter, process, and resolve claims from all PHC CIF claim types and in any form (paper or electronic) within established standards. This will include electronic and paper crossover claims, pended claims, and claims which require manual pricing.
- Participate in special projects and assignments as required.
- Recognize and give feedback to management on procedure changes that would result in more efficient operations.
- Record daily production statistics and related activities on appropriate reports; turn all logs and reports in to Claims Customer Service Supervisor. SECONDARY DUTIES AND RESPONSIBILITIES
- To provide support to CSR staff when call volume requires additional personnel.
- At the Supervisor's discretion and Manager's approval, a CSR III will be authorized to adjust their CIF'd claims. This authorization will be limited in scope to only those claim types they have demonstrated proficiency in and are consistently meeting both their quality and production goals.
- Provide the highest possible level of service to clients;
- Promote teamwork and cooperative effort among employees;
- Maintain safe practices; and
- Abide by the HealthPlan's policies and procedures, as they may from time to time be updated.
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