**Customer Service/Clinical Claims Representative**
Location: Wixom, MI JobFamily: Union Req #: PS68335 Date Posted: Feb 23, 2022 **Description:**
**Description**
SHIFT: Day Job
SCHEDULE: Full-time
Customer Service/Clinical Claims Representative
Wixom, MI (Remote)
This is an exceptional opportunity to do innovative work that means more to you and those we serve.
General Summary: Answer verbal and written customer/member/provider inquiries including questions regarding benefits, eligibility, and certifications. Quote accurate benefit and policy information regarding all levels of care. Combined responsibility for answering claims questions and initiating outpatient clinical authorizations based on parameters established by Clinical Director. Follow up with all customers/members/providers in accordance with Beacon Health Options standards. Ensure customer satisfaction and promote a positive corporate public image. Interact with various entities including Beacon Health Options Corporate departments to resolve issues. Handle verbal and written inquires, respond to customers/members/providers and follow-up accordingly, to the point of final resolution. Completion of special projects and all other duties as assigned, by Department Director, Manager or Customer Service Supervisor.
Essential Duties and Responsibilities:
* Answers telephone calls from members and providers identifying those within the parameters established as being handled in the Member Service Department including referrals, certifying outpatient services, quoting benefits, triaging crisis and urgent calls to clinical care managers.
* Interface with external and internal customers to ensure optimal efficiency of service. Address concerns of dissatisfied and or angry customers/members/providers in a diplomatic manner. Respond to customer inquiries professionally and efficiently. Educate, inform, and provide guidance to members/providers/customers/co-workers regarding the certification and claims process.
* Resolve in a timely manner customer/member/provider issues through investigation and problem solving. Process any related claim adjustments timely. Follow-up on inquiries as needed, referring problems to other appropriate Beacon Health Options personnel as identified. Keep all parties updated throughout the process.
* Document all inquiries and complaints, including their resolution, appropriately in Service/CareConnect.
* Communicate the correct procedure for submitting claims so that the claim can be processed. Explain the payment or denial results accurately as necessary to foster an understanding. Generate letters and correspondence to customers/members/providers explaining claim(s) resolution.
* Contribute to overall success of the department in meeting performance guarantees to customers and maintaining customer standards. Ensure that established work processes are followed accordingly.
* Apply Beacon Health Options policies and procedures consistently. Maintain Confidentiality of Clients, Business Records and Reports. Maintain ethical and professional standards. Maintain individual productivity and performance standards. Meet Departmental expectations, accuracy, productivity, and performance standards. Complete tasks accurately within required timeframes. Support Beacon Health Options in achieving Mission Statement. Adhere to the components of the Compliance Program. Ensure that job tasks are performed in a legal and ethical manner. Actively assess work area for non-compliance issues and notifies supervisor or call Ethics Hotline. Adhere to compliance training requirements and understand that training is a required condition of employment. Participate in corporate and service center quality and utilization management programs, as appropriate.
* Assist in training other personnel. Maintain access to all updated reference material. Manage all inquiry queues to the turnaround identified by manager. Ensure all inquiries are handled and closed appropriately.
* Complete all data entry from submitted forms such as outpatient registrations, case management or continuing care treatments. Ensure accurate capturing of date. Review scanned documents to ensure clarity of capture.
**Qualifications**
Minimum Qualifications:
Must possess a clear speaking voice and excellent telephone etiquette. Exhibited strong customer service orientation is required. Excellent verbal and written communication skills and problem-solving skills required. Ability to interact with others and resolve problems. Ability to compose a written letter to members/providers. Must be able to use pre-established screening guidelines and templates with accuracy. Ability to multi-task with a high degree of accuracy. Must be able to demonstrate ability to key with accuracy and pass a test of data entry skills. Must demonstrate the ability to: correctly adjudicate a claim; successfully handle a customer service test call; and accurately key data and test online while on the telephone.
* Education: A Bachelor' Degree and 2 - 3 years of combined experience in Customer Service and Claims Processing or Claims Research is highly preferred, however certification in Claims/Billing from an accredited business institution combined with 1 - 2 years of claims processing and/or claims research experience may be substituted.
* Licensures: N/A
* Relevant Work Experience: See education. Must also have knowledge and experience using management information systems and software; CAS or other computerized claims processing systems, word processing and spreadsheet applications (Microsoft Word and Excel).
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide and Anthem approves a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.
Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 Worlds Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ****** for assistance.
