CI/CR Representative - Claims

PrideStaff is a national staffing organization that specializes in temporary, temp-to-hire, and direct hire staffing. Our client is a national health care management and consulting company. They administer Medicaid, Medicare, commercial and employers' self-funded health benefit plans.

CI/CR Representative - Claims
This position insures accurate and efficient response to claims inquiries; including the maintenance of good provider relationships, the review and research of claim adjudication, resubmission and adjustment/correction to claims as required.

Responsibilities:
-Receive inquiries, from providers regarding claim status by telephone; answer call within established company standards
-Maintain an accurate online communications call log in accordance to department guidelines
-Analyze telephone communications for proper course of action (i.e., grievance or resubmission) and necessary research
-Determine if adjustment is warranted; take appropriate action as defined by department standards and policies
-Review history of claim in question; research particulars; contact appropriate personnel to verify information
-Identify and report issue trends in order to minimize future claims process issues
-Develop, establish, and maintain a work priority system to ensure daily and heavy workloads are fulfilled
-Maintain minimum telephone and claims processing standards
REQUIREMENTS
Requirements:
-High school diploma or equivalent required.
-Must have three (3) years basic medical claims experience in a Managed Care Organization and –Must have at least One (1) year advanced claims processing experience, including COB/TPL, reversals, appeals, grievances, special handling, analysis, and research.
- Preferred candidates will also have two (2) years customer service experience in a call center
-Must have exceptional oral and written communication proficiency; attention to detail and ability to multi-task.
-Able to research, analyze and successfully resolve a broad spectrum of issues.
-Intermediate skill level with Word and Excel required.
-Experience in claim adjudication with an automated claim processing system.