Claims Service Representative

Overview

Handles and triages all incoming calls for the claims department to ensure efficient routing and resolution. Receives and assigns first reports of injury from policyholders, employees, agents, and attorneys via phone, email, fax, and mail. Accurately inputs all relevant information into the claims system while maintaining data integrity throughout the process. Makes informed decisions on OWC and NCCI coding, including but not limited to nature of injury, cause of injury, injury description, and class code. Determines claim assignment to the appropriate lost time or medical only team. Enters all precertifications for medical treatment and/or testing into the claims system. Additional duties include indexing mail and medical bills in the medical bill review system.

Major Areas of Accountability

• Oversees accurate intake and complaint coding of newly reported claims into the electronic claims system and ensures alignment with regulatory standards and operational efficiency.
• Drives effective stakeholder communication to support seamless claims processing and service excellence.
• Enters precertification requests within the claims system, including the authorization of medical appointments.
• Must be able to interpret data on submitted forms to accurately enter coding for medical providers and treatment, to include ICD and CPT coding.
• Maintains up to date knowledge of claims policies and procedures to provide informed support to customers.
• Maintains the integrity and current correctness of the claims data.
• Performs claims indexing simultaneously in the medical bill review system, claims system, and document management system to ensure accurate and timely processing and payment of medical bills.
• Serves as resource person for less experienced team member personnel and assists in resolving technical questions or problems.
•  Assists in training of team members.
• Resolves customer issues and escalations. Also, identifies and transfers calls needing attention of a claim representative, claim specialist, or claims manager.
• When handling irate callers, will attempt to diffuse the situation by answering questions and assessing the needs of the caller.
• When necessary, will notify the Operations Supervisor to determine if security measures are indicated.
• Answers and handles claims customer service calls along with medical billing inquiries received by email.
• Approaches job in a conscientious and mature fashion, demonstrating a sense of responsibility. 
• Exhibits an ethical manner of conduct and keeps sensitive information confidential. 
• Demonstrates a willingness to contribute what is necessary to get the job done.
• Performs all duties and responsibilities in a timely and efficient manner in accordance with prescribed company policies and standards.
• Performs other duties and responsibilities assigned.

Personality/Working Style

• Strong character

• • Alignment with company values, mission, and vision
  • Trustworthy and honest
  • Decisive
  • Curious and persistent
  •  Displays emotional intelligence

• Passion for innovation

• • Willingness to learn
  • Adaptive to changing (tolerance for ambiguity)
  • Desire to collaborate to achieve corporate goals
  • Time management skills
  • Strong attention to detail and organizational skills

• Strong communicator

• • Possesses interpersonal skills, particularly over the telephone, with a strong customer-centered approach
  • Speaks and writes with clarity and confidence, backed by a solid grasp of grammar, punctuation, and tone
  • Empathetic listener and open-minded
  • Commitment to accountability
  • Possesses conflict resolution skills

• Technical skills

• • Data entry, computer, and organizational skills
  • Proficient in Microsoft Word, Excel, and Teams
  • Analytical skills for determination of proper coding
  • Knowledge of medical terminology, including occupational diseases
  • Knowledge of workers’ compensation jurisdiction and manual class codes
  • Knowledge of claims processing, OWC, and NCCI coding

Education and Experience

• High school diploma or equivalent
• Minimum of three to five years’ experience working in an insurance office environment 
• Knowledge of workers’ compensation claims processing and medical technology preferred

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