Remote Claims Specialist
Job Summary The Service Center Representative processes medical claims and communicates with providers about the claims process. The position is responsible for daily claims management and is recognized as a general technical expert in the health benefits program. The Service Center Representative expedites the claims process and provides detailed claim notes on all calls; as well as resolves issues and directs calls to an appropriate escalation path as needed. Essential Functions Duties and Responsibilities Acts as primary liaison with callers; follows client specifications in assisting with questions and solving problems related to the claims process and servicing processes. Educates and informs the customer via multiple communication channels about documentation required to process a claim, required time frames, payment information, and claim status. Educates members and providers on client requirements and benefit plans documenting all required details of the call in a concise professional manner. Enters verbal and written application information that meets both the internal and external customer's requirements accurately into the claims management system. Assigns new claims to the appropriate claims handler. Directs customer calls to the appropriate contact at multiple locations or escalates to Service Center Specialist/management as needed. Attendance during scheduled work hours is required. Performs other duties as assigned. Supports the organization's quality program(s). Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. While performing the duties of this job, the employee is regularly required to sit, talk, and hear. The employee frequently is required to use the fingers to make small movements such as typing, picking up small objects, or pinching fingers together. The employee is occasionally required to walk; reach with hands and arms; stoop, kneel, crouch, or crawl. Sedentary work. Sitting most of the time. Specific vision abilities required by this job include close vision, peripheral vision, depth perception, and the ability to adjust focus. The employee moves within the facility in which their office is located to access file cabinets, documents, office machinery, and other equipment. They also travel within their home office or facility in which their office is located and to locations outside of the facility, to attend meetings, training, events, and other business activities. An employee in this position may lift, carry, push, and/or pull objects weighing up to 10 lbs. Occasionally may move objects weighing up to 10-20 lbs. The employee holding this position must have strong communication and organizational skills, and an ability to interact and work with others. They must be able to work under time constraints and deadlines. Job Specifications GOVERMENT SOLUTIONS SERVICE CENTER REP: This will be inbound calls to providers so understanding how offices operate would be beneficial but not essential. Claims and Customer service is priority for experience, Spanish speaking will be a plus, not mandatory Education High School diploma or GED required. College courses preferred. Experience One (1) year of customer service and claims experience or an equivalent combination of education and experience is required. Inbound call center experience preferred. Other Skills and Abilities, Qualifications Knowledge of medical terminology Understanding of claims management Excellent oral and written communication PC literate, including Microsoft Office products and must be comfortable on camera when requested. Analytical and interpretive skills Strong organizational skills Good interpersonal skills Ability to multitask in a fast-paced environment Ability to support multiple clients across communication channels and utilize multiple systems simultaneously Ability to work in a team environment and/or independently. Ability to meet or exceed Performance Competencies and must be a US citizen NOTE: Credit security clearance, confirmed via a background credit check, is required for this position. Conditions of Employment Work environment The work environment characteristics are representative of those an employee encounter while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. Persons holding office positions are generally subject to environmental conditions having the lighting, temperature, and noise of an open-floorplan office environment. Nesco Resource offers a comprehensive benefits package for our associates, which includes a MEC (Minimum Essential Coverage) plan that encompasses Medical, Vision, Dental, 401K, and EAP (Employee Assistance Program) services. Nesco Resource provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
