Provider Claims Service Representative

Responsibilities:

Under the general direction of the Operations Call Center Supervisor, responsible for responding in a timely, professional and courteous manner to all customer needs. This includes provider phone calls or correspondence regarding benefit, eligibility, and other provider issues. Reviews and adjudicates claims based on provider and health plan contractual agreements and claims processing guidelines. Serves as a Subject Matter Expert. Conducts cross training to staff as required. Demonstrates solid knowledge of Provider Service/Claim systems, functions and team process. Demonstrates superior skill in dealing with provider issues/inquiries, team members, and co-workers. Suspends claims requiring additional information and/or special handling; initiates action to obtain required information. Forwards claims requiring external department intervention to the appropriate department or person. Monitors outstanding inquiries and works with management staff to identify and resolve areas of non-compliance. Reviews and verifies quality audit reports. Reconciles audit discrepancies, corrects in system and make appropriate changes to avoid recurrence. Maintains thorough knowledge of claims process systems, its databases and subsystems. Responds to and resolves provider and health plan claim inquiries. Monitors and tracks aged, pended, and open reports to maintain timeliness in claims processing. Inputs claims into the system for appropriate tracking and processing. Documents file, as appropriate, to support payment decision. Serves as a Subject Matter Expert and conducts training as required. Conducts cross training to staff as required. Actively participates in user acceptance testing functions, such as test script development, testing and documentation of test results.

Education/Experience:

Minimum 4 years' experience in claims and/or call center required. High School/GED required. Associate degree preferred; minimum 45 wpm typing preferred. Healthcare or Managed Care experience preferred. Working knowledge of PC apps in a windows based environment.

Training Information:

Training is conducted onsite Monday through Friday from 8:30 AM - 5:00 PM and lasts approximately 6-7 weeks (maximum) . During this period, you are required to be fully available and onsite for the entire duration of training . Upon successful completion of training, the role will transition to a remote work environment . However, you may be required to report to a business office for mandatory meetings and/or technical support related to remote work .

Work Schedule:

Our Contact Center operates 24 hours a day , and this position requires flexibility to work shifts between 7:00 AM - 7:00 PM . Start times will vary on a weekly basis, typically ranging from 7:00 AM to 10:30 AM , and are assigned based on business needs (example shift: 10:30 AM - 7:00 PM ). Your permanent schedule will be assigned toward the end of training and will remain consistent based on operational needs. Our Comprehensive Benefits Package Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents starting Day 1, 401(k) retirement savings plan, tuition reimbursement, and more.

Why Join Us:

Your career starts now. We are looking for the next generation of healthcare leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you are driven to make a difference, we want to hear from you. About AmeriHealth Caritas Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. Our services include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at http://www.amerihealthcaritas.com