Claims & Customer Service Representative II

Summary: The Claims/Customer Service Representative II has the skills to handle all calls through the call center. They are responsible for providing answers to all incoming calls from clients, members, and providers. If a call requires additional research, Representative is responsible for gathering the information and making the call back. They will also have the skills to process all claims for payment in Medical, Dental and Vision products. Assists clients and staff on all plan/claim questions. Essential Functions: · Responsible for all calls as they relate to member benefits, eligibility, and claims processing/billing. · Document all calls in the claim system for tracking and reporting. · Create/monitor follow-up reports to ensure call backs and follow ups are being completed timely. · Read, interpret, and understand Plan Documents and Summary Plan Descriptions to appropriately verify benefits, eligibility, and determining coverage, out-of-pocket, etc. · Maintain customer service/claims desk reference book with the most current plan information. · Review each claim for accuracy and complete information. · Research and gather all information needed to process claims by contacting client, member or health provider when needed. · Follow claim through payment, denial, and appeal. · Research/problem solving. · Back up to assigned positions. Supervisor Responsibilities: N/A Knowledge, Skills, Abilities: · Has excellent communication skills (verbal and written); professional, courteous, polite, tactful) · Clerical skills which include but are not limited to mailroom, indexing and operational support. · Has excellent telephone etiquette and can remain calm under pressure. · Maintains a positive attitude towards clients and staff. · Has excellent organizational skills · Understands and can interpret health benefit terminology. · Can maintain strict confidentiality and is HIPAA compliant. · Can solve problems independently. · Understands all lines of coverage. · Understand claim forms/billings, codes, terminology, and procedures (Coordination of Benefits, COBRA, Medical and ancillary Plans, Stop Loss, reinsurance carrier, Medicaid, Medicare, and IRS rules). · Has a high level of math aptitude and detail. · Able to prioritize and follow through. · Is competent user of computer software and internet. · Speed and accuracy in processing claims to conclusion. Qualifications: · Has a high school diploma or equivalency. · 5 + Years TPA claims and/or call center experience. · Experience with CMS regulations pertaining to Medicare Supplement and EGWP Rx plans a plus. Success Factors: · Can stay positive and professional when dealing with providers and clients. · Can multi-task · Can follow through with attention to detail. · Able to work independently but team player. · Consistently meets/exceeds financial and procedural audit goals. Job Type: Full-time Benefits: 401(k) 401(k) matching Dental insurance Employee assistance program Flexible schedule Flexible spending account Health insurance Health savings account Life insurance Paid time off Vision insurance Experience: Microsoft Office: 3 years (Required) Customer service: 3 years (Required) Work Location: Hybrid remote in Grand Rapids, MI 49546