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Customer Service Representative 1
Ref No.: 18-11360
Location: New Albany, Ohio
Start Date / End Date: 09/04/2018 to 09/03/2019
Duration:6-12 month(s)

These positions will include weekend rotation hours, and the work schedule could be from 8:00am – 8:00pm. Microsoft Office 2010 testing of Word, Excel, Outlook, and Telephone Etiquette, all test scores MUST be attached to each candidates resume to be considered.

Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff. Documents and tracks contacts with members, providers and plan sponsors. (*) • Explains member's rights and responsibilities in accordance with contract. (*) • Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system. (*) • Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues. (*) • Responds to requests received from Healthcare's Law Document Center regarding litigation; lawsuits. (*) • Handles extensive file review requests. Assists in preparation of complaint trend reports. Assists in compiling claim data for customer audits. (*) • Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals. (*) • Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management .(*) • Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary. (*) • Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.