Position Summary 

Customer Service Specialist is responsible for providing support to network providers, medical offices and billing companies. The customer service specialist will answer questions regarding eligibility, authorization, network guidelines, claims status and general health plan information. 

Duties and Responsibilities

· Answer calls, from providers to verify eligibility and provide them with claims payment status. 

· Search for members navigating through the TPA System and main health plan sites in order to check on member eligibility. 

· Read and comprehend paid and denied claims and explain denial codes. 

· Educate providers on the appeal/claim submission process and provider portal use.

· Demonstrate professional etiquette and courtesy when interacting with providers.

· Accurately and comprehensively documents all communications from providers based on organization policies and procedures through investigative research to create internal PDR’s. internal open tickets.

· Assist the Claim Department by entering appeals in the TPA System.

· Assist the health plan by providing participating physicians information within the network per line of business (LOB). 

· Assist the other customer service representatives on escalated issues.  

· Support coverage for mailroom 

· Support coverage for EDI Specialist

· Process daily pending eligibility review for claims department workflow.

· Generate provider letter weekly for rejected claim.

· Generate and mail daily NABD & NDP letters.

· Create refund letters and upload supporting documents in the claims processing system

· Review deductibles and out of pockets accumulators’ queue for claims department

· Distribute faxes that are received daily to all departments. 

· Performs other duties as assigned by Management.

Knowledge

· Specialty Network experience in Claims and/or Customer Service is required. 

· Minimum of three (3) years of experience in the Healthcare industry.

Skills

· Fluent in English and Spanish; oral and written communication. 

· Microsoft (Outlook, Excel, Work, and PowerPoint).

· Accurate Data Entry. 

· Sales Skills.