Claims Customer Service Representative - CA

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. Provides primary support for California jurisdictional claims. 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. Please note that this position has an end shift time of 6:00 pm. 

· Inputs notes into medical bill review web-based system for disputes/denials.

· Manually produces claim welcome packets as requested.

· Researches outstanding checks for escheatment process and mails form letter to check recipient if applicable.

· Forwards travel documents back to sender requesting additional information.

PRIMARY RESPONSIBILITIES: (Brief bullet points detailing the major duties, not tasks, for this job and the % of time spent on each. Please list them in the order of importance).

· Supports the customer service work and processes for the Enterprise claims teams as well as the Subrogation Teams.

· Answers claim inquiries from policyholders, agents, injured workers, attorneys, pharmacies, medical providers for multiple jurisdictions for the Enterprise claims teams. Provides verification of claim status for multiple jurisdictions using multiple technology sources.

· Performs all facets of IME’s, AME’s, DDE’s, QME’s and any other independent type evaluation needed for the claim file.

· Provides backup as needed to Claims Document Analysts to review and analyze incoming documents and assign the appropriate document sub type to them.

· Reviews each document and adds pertinent information to the document keywords and to appropriate data fields in the claim system.

· Re-indexes and appropriately routes documents that have been assigned an improper document type or have been attached to an incorrect claim.

· Downloads electronic medical records from various vendors.

· Assists with the resolution of FROI errors.

· Adds legal matters and pertinent litigation information to the claim system upon receipt of legal documents.

· Reviews, researches, and properly routes all unidentified claims mail for all brands within the Enterprise.

· Provides backup to the Claims Processing Associates for review, research, and proper routing of priority unidentified claims mail for all brands within the Enterprise.

· Processes Claims Subpoenas. Performs all facets of the following referrals: Utilization review, Medical Management, Vocational Rehabilitation, Litigation, and all other Vendor Referrals as requested.

· Participates in projects to improve processing and workflow.

· Provides PPO, MPN, HCN provider names and/or general program information to customers

· Updates claim system with vital information changes.

· Updates document management system when claim number changes occur.

· Provides backup to intake for multi-state claims processing.

· Produces forms, memos, reports, information and letters as requested.

· Provides policyholders, agents, and others as requested with copies of first report of injuries.

· Corrects department and location information on loss runs as requested.

· Inputs data into legal billing system.

· Types, photocopies, faxes as necessary.

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

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

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

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

· May participate with training of team members.

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

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

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

Additional duties for California claims include but are not limited to:

· RFA processing on claims.

· IMR/IBR processing on claims.

· AME/QME processing on claims.

· Re-index claims on ISO website.

· File and Serve appropriate documents to Primary Treating Physician on claims.

· Generate Lien Objection Letters on claims.

· Request medical records on claims via Vendor.

· Generate and mail Enzyme letters to Injured Workers and Treating Physicians on claims.

· Create Special Handling Forms with all applicable data for Medical Liens on claims.

EMPLOYMENT QUALIFICATIONS:

A. EDUCATION REQUIRED:

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

B. EXPERIENCE REQUIRED: 

Minimum one year of experience with AF Group as a Claims Customer Service Representative. Minimum of three years general office experience. Prior experience answering inquiries, exchanging information, and resolving complaints over the phone at AF Group is required.

OR

Minimum of four years of general office experience including. Two years of customer service with insurance related experience in a claims environment that includes exchanging information over the phone, resolving complaints, and answering basic inquiries. Prior equivalent relevant experience that would provide the necessary skills, knowledge and abilities may be considered.

C. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: 

· Demonstrated ability to review, analyze, interpret, and follow instructions to appropriately perform procedures related to assigned tasks.

· Demonstrated knowledge of insurance claims processing.

· Demonstrated knowledge of internal/claims workflows.

· Experience with Claims systems.

· Excellent customer service skills.

· Excellent telephone etiquette.

· Excellent verbal and written communication skills.

· Excellent organizational skills and ability to prioritize work.

· Excellent attention to detail.

· Ability to manage multiple priorities and meet established deadlines.

· Knowledge of multi-functional telephone system.

· Ability to research information in multiple systems.

· Ability to obtain pertinent and thorough information from customers.

· Ability to be an independent thinker to solve issues.

· Ability to work effectively with various business units.

· Excellent organizational skills and ability to prioritize work to meet established deadlines.

· Knowledge of computers and spreadsheet software.

· Ability to proofread correspondence for accuracy of spelling, grammar, punctuation, and format.

· Knowledge of word processing software with data entry ability of 40 w.p.m.

· Ability to verify data for accuracy.

· Knowledge of medical terminology.

· Knowledge of legal terminology.

· Ability to multi-task, i.e. interacts on telephone while entering data.

· Ability to train and coach others to perform the core responsibilities.

· Ability to work varied hours/days/shifts.

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

D. ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED: 

· Insurance Institute of America (IIA) Certification.

· Prior experience supporting claims in California Jurisdiction is preferred.

· Spanish fluency (Premium will apply upon completion of Spanish testing requirements.)

· 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.

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