Claims Customer Service Representative

SUMMARY: 

Primarily responsible for the customer service process associated with workers compensation claims which includes servicing customers who contact us via the ACD phone line and supporting the claims management process for all claims teams across the Enterprise.  Acts as a back up to the claims intake process. Acts as a backup to the Service Center Business Development and Provider Relations teams on the ACD phone line. 

Note- This position has an end time of 6:00 pm. 

1. Inputs notes into medical bill review web based system for disputes/denials.
2. Manually produces claim welcome packets as requested.
3. Researches outstanding checks for escheatment process and mails form letter to check recipient if applicable.

4. Forwards travel documents back to sender requesting additional information.

5. Types, photocopies, faxes as necessary.

6. Organizes file materials in date order to be provided to various attorneys and vendors either via the vendor portal or another delivery method.

7. Assigns services requests to TPA and other vendors via the vendor portal.

8. Communicates with appropriate state WC division to discuss various issues.

9. Makes contact with employer and/or injured worker if necessary to obtain information.

10. May participate with training of team members.

11. Serves as a resource with creation of documentation of general and state specific procedures as it relates to this position.

12. Communicates and collaborates with team members to ensure the appropriate and timely handling of claims.

13. Performs all tasks specified for multiple jurisdictions for all Enterprise Claims Teams. 

This description identifies the responsibilities typically associated with the performance of the job. The percentage of time in any responsibility may vary between positions.  Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

1. EDUCATION REQUIRED: (Brief paragraph detailing the minimum education required, including certifications) Do not state preferred qualifications.

High School Diploma or G.E.D. required.   Minimum of an Associates degree in insurance or related field, but a combination of education and experience may be considered in lieu of formal education.   

1. EXPERIENCE REQUIRED: (Minimum experience required to perform this job) Do not state preferred experience.

Minimum of three years general office experience including a minimum of one year in workers’ compensation insurance.    Prior experience answering inquires over the phone at AF Group or equivalent relevant internal experience that would provide the required skills, knowledge and abilities. Relevant customer service experience exchanging information and answering basic inquiries over the phone is required

OR

Minimum of four years of general office experience. Two years of customer service experience answering inquiries over the phone in an insurance organization. Prior equivalent relevant experience that would provide the required skills, knowledge and abilities may be considered.

1. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: (Brief bullet points detailing the skills, knowledge, and abilities required for this job. SKA’s should tie back to the primary responsibilities required)
2. Basic knowledge of insurance claims excellent customer service skills.
3. Excellent telephone etiquette.
4. Excellent verbal and written communication skills.
5. Excellent organizational skills and ability to prioritize work.
6. Ability to manage multiple priorities and meet established deadlines.
7.  Knowledge of multi functional telephone system.
8. Ability to research information in multiple systems.
9. Ability to obtain pertinent and thorough information from customers.
10. Ability to be an independent thinker to solve issues.
11. Ability to work effectively with various business units.
12. Excellent organizational skills and ability to prioritize work to meet established deadlines.
13. Knowledge of computers and spreadsheet software.
14. Ability to proofread correspondence for accuracy of spelling, grammar, punctuation, and format.
15. Knowledge of word processing software with data entry ability of 40 w.p.m.
16. Ability to verify data for accuracy.
17. Knowledge of medical terminology.
18. Knowledge of legal terminology.
19. Ability to multi-task, i.e. interacts on telephone while entering data.
20. Ability to train and coach others to perform the core responsibilities.
21. Ability to work varied hours/days/shifts.

22. Ability to assist with the creation of procedural documentation and workflows.

     

23. ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED: (Briefly detail the preferred education, experience, skills, knowledge and/or abilities desired to perform this job, including certifications). These are in addition to the required qualifications - Do not state required qualifications.

• Insurance Institute of America (IIA) Certification
• Experience handling claims in multiple states.
• Experience on an ACD telephone system
• Experience using a document management system with workflows

• Knowledge of CPT, ICD9 and 10, and drug codes

   

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards. This position has an ending time of 6:00 pm.

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