Job Description

The Claims Call Center Representative will provide superior and responsive customer service researching and resolving questions and concerns from members and providers.  The Claims Call Center Representative is responsible for interacting with medical offices, health plans, members and their representatives to educate, support and follow up on claim status or payment inquires.


Summary of Essential Duties and Responsibilities


  • Handle inbound and outbound phone calls in a courteous, timely, and professional manner
  • Listen to customers, understand their needs, demonstrate empathy, and resolve member and provider questions and concerns
  • Utilize the enrollment and claims systems to complete full research of the question or concern
  • Accurately document all discussions and actions taken in appropriate systems
  • Follow all required scripts, policies, and procedures
  • Utilize knowledge base and training to accurately answer questions
  • Appropriately escalate customer issues with the management team
  • Ensure first call resolution through problems solving and effective call handling 
  • Review edits, error codes, suspend edits and warning messages to help convey the history and issues with processed or suspended claims.
  • Research's and assists team and management with claim projects, claims processing discrepancies, eligibility issues and claim rejections
  • Refer claims for medical management claim review as necessary/applicable
  • Maintain a minimum of 98% accuracy at all times
  • Filing and light administrative duties associated with claims processing
  • Other duties and responsibilities as may be assigned.


Minimum Requirements


  • High School diploma or GED equivalent
  • Experience in healthcare claims processing or call center preferred
  • Computer proficiency in a Windows environment, knowledge of Microsoft Office products


Abilities Required


  • Ability to manage multiple tasks and prioritize work to adhere to deadlines and identified time frames
  • Ability to read, write and communicate at a professional level
  • Effective time management and organizational skills
  • Effective interpersonal and communication skills