Delta Health Systems one of the leading Third Party Administrators (TPA) for self insured programs in the country with a reputation for flexibility, innovative services and outstanding customer service is looking for innovative, self motivated, dedicated individuals to fill positions for:
Customer Service Representative – Claims Processor
Fresno, CA
POSITION RESPONSIBILITIES
· Handles general inbound ACD calls related to all aspects of service. Effectively communicates, Delta Health Systems policies, procedures and applicable benefits to members and/or providers
· Researches claims according to established policies and procedures. Determines claim status and consults with appropriate staff and/or management on all questionable claims in order to ensure proper disposition.
· Must meet departmental standards for quality, productivity and teamwork. Communicates accurate information to customer questions and requests, by phone, in a courteous and professional manner. Able to handle difficult and sensitive issues appropriately; maintains highest level of customer confidentiality.
· Investigates customers’ problems as indicated. Initiates appropriate action to ensure timely resolution. Interacts with staff to clarify problems presented by customers to obtain accurate information.
· Maintains a comprehensive knowledge of all Delta Health Systems policies, procedures, products and services.
· Research and interpret claims, including all aspects of COB, worker’s compensation and claim recovery.
· Interpret Delta Health Systems remittance advices and member EOB’s
· Performs data input in a highly accurate and timely manner for all customer contacts and assures documentation is complete.
· Has an understanding of, and is able to communicate member benefits, reimbursement policies, coding guidelines, the appeal procedures and company policy to all customers.
· Evaluate claims and determine payment or denial according to Plan provisions, Medical Policy and Department guidelines
· Key all final information for claims release into computer
· Maintain information files, worksheet records, benefit quote documentation
· Establish and maintain COB files, applies COB payments for final claim payment
· Research and determine proper CPT procedure and ICD-9 Diagnosis Codes
· Prepare transmittal and send claims to Benefit Review for processing instructions
· Work effectively to achieve acceptable production and accuracy standards
· Perform other duties as assigned
KNOWLEDGE AND SKILL
12 months experience in claims processing or customer service in a medical claims processing environment. Must have a broad knowledge of medical terminology and must possess excellent oral communication skills. Must possess good judgment skills and ability to interpret Department guidelines and contractual benefits and possess a high school diploma or equivalent.
Delta Health Systems is committed to long-term growth, employee development and superior client service. Join a great team with terrific total comp package.
Equal Opportunity Employer