Customer Service Consultant

Position Summary/Mission
Reviews and adjudicates claims in accordance with claim processing guidelines. Handles customer service inquiries and problems via telephone, internet or written correspondence. Act as a subject matter expert by providing training, coaching, or responding to complex issues. May handle customer service inquiries and problems. Acts as end-to-end contact for clients experiencing claim and/or customer service problems

Fundamental Components & Physical Requirements:

Handles telephone and written correspondence from varied sources (providers, members, plan sponsors, attorneys and other company personnel). Also reviews claims cost payments in order to respond to all requests for reconsideration or appeal. Makes outbound calls if necessary for client follow-up.

Perform a wide variety of customer service related functions, including phone calls, written inquiries, out reach programs, and walk-ins. Explains customer/member specific plan of benefits along with member's responsibilities in accordance with contracted arrangements.

Processes rework claims to minimize customer hand-offs and improves single call resolution.

Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines.

Diaries, reviews, and manages all pending claims and claim follow-ups daily focusing on earliest release possible.

Handle complaints (member/provider), grievance and appeals (member/provider) via relevant recording/reporting system.

Ensures compliance with requirements of regional compliance authority/industry regulator.

Responsible for managing complex claim research scenarios and serving as a technical resource to colleagues on claim resolution, triaging of claim pre-authorization issues, and similar situations requiring senior level expertise.

Documents and tracks all member contacts, events, and outcomes via appropriate systems.

Works to enhance provider satisfaction while balancing interests of plan sponsor and member; keeps abreast of all network nuances (disruptions, terminations, additions, unique contract items, etc.).

Accesses information from a variety of systems and references including contracting and network system.

Identifies systemic provider issues and partners with the appropriate parties for resolution.

Adheres to international privacy policies, practices and procedures.

Exhibits the following

Employee Behaviors Background

2-3 years experience in a production environment preferred.

Claim processing experience.

Customer Service experience in a transaction based environment.

Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

Education and Certification Requirements

High School graduate as a minimum

University/college degree preferable or equivalent work experience.

Additional Information

Analytical skills.

Ability to maintain accuracy and production standards.

Technical skills.

Oral and written communication skills.

Understanding of medical terminology.

Strong knowledge of benefit plans, policies and procedures.

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