Claims Customer Service Representative

Innovative Integrated Health, through PACE by IIH, provides community-based healthcare and support services for senior participants. The Claims Customer Service Representative serves as a liaison between the company and external healthcare providers, handling claim inquiries, resolving claim issues, and ensuring accurate, compliant communication and documentation.

Responsibilities:

• Respond to Provider inquiries regarding medical and dental claims via phone and email
• Research and resolve issues related to claims status, denials, and payment discrepancies
• Maintain up-to-date knowledge of benefit plans, claim adjudication guidelines, coding requirements, and HIPAA regulations
• Accurately document all interactions and claim actions in the Company system by compliance standards
• Maintain accurate records of interactions and claim resolutions
• Communicate complex benefit details in a clear and concise manner to Providers
• Collaborate with internal departments to facilitate resolution of claims-related issues
• Recommend process improvements to enhance service delivery and improve Provider experience
• Provide empathetic and efficient service to when working with Providers
• Ensure all duties are completed with a focus on quality, compliance, and Provider satisfaction
• Maintain punctuality, professionalism, and adherence to company policies and attendance requirements
• Attend and participate in audits, staff meetings, in-services, and other projects as assigned
• Adhere to and support the center’s practices, procedures, and policies including assigned break times and attendance
• Accept assigned duties in a cooperative manner; and perform all other related duties as assigned
• Flexibility to adjust schedule as needed to meet operational demands

Requirements:

• Proficient in Microsoft Office (Excel, Outlook, Word)
• Familiarity with medical billing terminology (ICD-10, CPT, HCPCS) and Explanation of Payments (EOPs)
• Strong oral and written communication skills
• Proven ability to multi-task and remain detail-oriented under pressure
• Strong interpersonal and problem-solving skills; collaborative mindset
• Ability to learn and apply regulatory requirements quickly
• Ability to access all areas of the center throughout the workday
• Ability to lift a minimum of 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance of another employee when attempting to lift or transfer objects over 50 pounds
• Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching forward and overhead; squatting and kneeling
• Ability to communicate verbally with an excellent comprehension of the English language
• Work is generally performed in an indoor, well-lit, well-ventilated, heated, and air-conditioned environment
• Minimum of two (2) years work experience required
• At a minimum a High School Diploma or GED is required
• Is medically cleared for communicable diseases and has all immunizations up-to-date before engaging in direct participant contact
• knowledge of claims processing software, preferred
• Minimum of one (1) year of experience working in a healthcare call center, preferred
• Experience working remotely, preferred