Position Overview
The Claims Service Correspondent is responsible for accurate and timely responses to written claim inquiries received from providers. This individual provides support regarding the adjudication and adjustment of claims for multiple lines of business. They will work closely with Provider Contracting, Medical Management, Enrollment and Membership department, and Claims Processing unit.
Scope of Role & Responsibilities
- Act as a key liaison and service representatives for all written provider inquiries and problem resolution.
- Respond to all claim inquiries from provider sites including physicians, clinical staff, and site administrators.
- Coordinate and track appropriate problem resolution activities with plan personnel in other departments (i.e., Claims, Utilization Management, etc.)
- Manage and ensure appropriate follow-up and closure for all inquiries.
- Respond to providers’ inquiries in writing and maintain accurate tracking.
- Data entry into the Claims Processing and Correspondence Distribution systems.
- Perform claim adjustments to correct erroneous payments (overpayments/underpayments).
- Perform claim adjustments due to Authorization Appeals and Retro Reviews.
- Participate in special projects involving Claim Status Investigations.
- Resolve Member Bills referred from Member Services.
Required Education, Training & Professional Experience
- High School Diploma required.
- Minimum 2 years of experience in claims processing protocols and payment schemes.
- Proficiency working in a comparable Claims Processing Database.
- Thorough knowledge of health benefits plans.
- Must be able to resolve concerns with providers in a professional manner.
Professional Competencies
- Integrity and Trust
- Customer Service Focus
- Functional/Technical skills
- Written/Oral Communication
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