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TALENT Software Services · 1 month ago

Claims Customer Service Advocate II

Myrtle Beach, SC

Full-time

Onsite

New Grad, Entry Level

$17.75/hr - $17.75/hr

TALENT Software Services is seeking a Claims Customer Service Advocate II to handle customer inquiries and adjudicate claims. The role involves ensuring effective customer relations, processing claims, and resolving complex inquiries with adherence to organizational policies.

Artificial Intelligence (AI)ConsultingDevOpsHealth CareIT ManagementProject ManagementRecruitingStaffing Agency

Growth Opportunities

Responsibilities

Responsible for responding to customer inquiries. Inquiries may be non-routine and require deviation from standard screens, scripts, and procedures. 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

Ensures 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

Examines 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

Ensures claims are processing according to established quality and production standards

Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution

Identifies and reports potential fraud and abuse situations