Responsible for responding to customer inquiries.
Performs research as needed to resolve inquiries.
Reviews and adjudicates claims and/or non-medical appeals.
Determines whether to return, deny or pay claims following organizational policies and procedures.
Ensure effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries.
Handles situations which may require adaptation of response or extensive research.
Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
Examine and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes.
Ensure claims are processed according to established quality and production standards.
Identify complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refer these to a lead or manager for resolution.
Identifies and reports potential fraud and abuse situations.

High School Diploma or equivalent
2 years of customer service experience including 1-year claims or appeals processing OR Bachelor's Degree in lieu of work experience
Good verbal and written communication skills.
Strong customer service skills.
Good spelling, punctuation and grammar skills.
Basic business math proficiency.
Ability to handle confidential or sensitive information with discretion.
Required Software and Other Tools: Microsoft Office.

Claims Customer Service Advocate II

Key skills