Job Summary:Responsible for customer service calls from providers in assisting callers as it relates to the claims adjudication. Acts as the “first impression” person representing RCMG to callers. Provide claim status and assistance as directed by Supervisor. Research and respond to eligibility claim issues.
Essential Job Functions:Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the position.
• Provides a full range of assistance to providers via telephone or correspondence concerning claims.
• Answers telephone in a prompt, professional, courteous and helpful manner; responds to questions regarding claims status and eligibility inquiries.
• Responsible for maintaining and logging accurate phone calls in the Customer Service Module within the Portal and forwarding any potential adjustments via call ticket to the appropriate unit.
• Demonstrates a comprehensive knowledge of Health Plan Benefits and the various departmental functions.
• Analyzes and identifies concerns/issues and refers to appropriate department if deemed necessary.
• Evaluates and processes claims and claim adjustments in accordance with company policies and procedures according to productivity and quality standards.
• Interprets and processes routine to moderate claims inquiries.
• Checks for erroneous items or codes and missing information and corrects errors according to established procedures.
• Maintains current knowledge of RCMG members' benefits, policies/procedures, provider network development and contract issues, processing system issues, Medi-Cal regulations, as well as industry standards for claims adjudication.
• Researches, updates and/or adds eligibility to previously entered claims.
• Consistently maintains production standards based on transactions/units per hour.
• Consistently meets quality standards.
• Performs other related duties consistent with the scope and intent of the position.
• Regular attendance.
Other Functions:• Enforces Company policies and safety procedures.
• Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
Competencies• One (1) year experience in a Customer Service Call Center required.
• Claims experience in managed care claims processing preferred.
• Familiarity with ICD-9/10, HCPCS, CPT coding, modifiers, DMHC regulations, facility and professional claim billing practices.
• Ability to maintain production level and quality goals.
• Ability to demonstrate self-motivation, multi-task, exercise excellent time management, follow through on commitments and meet multiple deadlines.
• Work product demonstrates excellent attention to detail, is accurate, thorough and effective.
• Excellent communication skills, including both oral and written.
• Excellent active listening and critical thinking skills.
• Ability to solve entry to mid-level problems with supervision.
• Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers.
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to maintain confidentiality and appropriately share information on a need to know basis.
• Ability to consistently deliver excellent customer service.
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
• Demonstrate commitment to the organization’s mission.
• Must have mid-level skills in Microsoft software (Word, Excel, PowerPoint).
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using e-mail applications.
• Ability to work independently as well as in a team environment.
• Ability to present self in a professional manner and represent the Company image.
Supervisor Responsibility• This position does not have any supervisor responsibilities.
Education and Licensure• High School diploma or equivalent required.
• Associate degree preferred.
Travel• The incumbent may travel up to 5% of the time.
Work EnvironmentThis job operates in a professional office environment. This role routinely uses office equipment such as computers, phones, photocopiers, scanners and filing cabinets.
Mental and Physical DemandsThe physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
While performing this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands to finger, handle, or feel; and reach with hand and arms.
The employees is occasionally required to sit; climb or balance; and stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.
Experiences frequent interruptions; required to meet inflexible deadlines; requires concentration and attention to detail; requires a high level of organizational and prioritization skills.
Required to sit for prolonged periods; exposed to visual display terminal for prolonged periods; dexterity and precision required in the operation of a computer.
Other DutiesPlease note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.