Job Title: Claims Customer Service Representative

Department: Claims Effective Date: January 12, 2022

Reports to: Claims Support Supervisor

Direct Reports: None

FLSA: Non-Exempt

Working Conditions: Normal, no adverse or hazardous conditions.

Primary Purpose:

 To provide high level customer service to PDTs’ clients in accordance with accuracy. Principal Duties and Responsibilities (* = essential functions):

 Answer calls from members, providers and health plans regarding specific claim issues. Route and redirect calls as necessary.*

 Return calls from the Claims voicemail box.*

 Perform timely follow-up on calls requiring research and call back.*

 Accurately interpret DOFRs – Division of Financial Responsibility documents that determine who pays for specific health care services (PDT, health plan or other). *

 Use MedMC software to log incoming call and resolution of the call. *

 Act as back-up resource to cover front desk phones/greet walk-in guests, data entry of paper claims and open/sort/batch incoming claims mail.

 Complete other tasks as assigned. Job Specifications (KSAs):

 Requires the ability to speak, read, write and understand English and other general educational skills as is generally obtained by completing high school or a GED.

 Knowledge of health or managed care industry as generally obtained through 1-2 years of work experience. Position Performance Criteria:

 Consistently produces accurate and timely work product as it relates to departmental goals.

 Demonstrates high reliability through consistent punctuality and attendance.

 Competently performs position requirements with minimal supervision and direction, including taking initiative and assuming responsibility for follow through.

 Demonstrates excellent interpersonal skills as discerned through observation and team project successes.

 Accurately interprets and applies departmental policies and procedures using sound judgment.

 Communicates clearly, professionally and respectfully to peers, superiors, subordinates and clients.

 Demonstrates overall professionalism in attitude, demeanor and personal appearance