Service Center Representative

Job Summary:

The Service Center Representative processes medical claims and communicates with providers about the claims process. The position is responsible for daily claims management and is recognized as a general technical expert in the health benefits program. The Representative expedites the claims process, provides detailed claim notes on all calls, resolves issues, and directs calls to the appropriate escalation path when necessary.

Essential Functions, Duties, and Responsibilities:

• Primary Liaison: Acts as the primary point of contact for callers, following client specifications to assist with questions and resolve issues related to the claims and servicing processes.
• Claims Education: Educates members and providers on documentation required to process a claim, required time frames, payment information, and claim status via multiple communication channels.
• Information Entry: Accurately enters verbal and written information into the claims management system to meet internal and external customer requirements.
• Claims Assignment: Assigns new claims to the appropriate claims handler.
• Call Management: Directs customer calls to the appropriate contact at multiple locations or escalates to Service Center Specialist/management as needed.
• Attendance: Ensures attendance during scheduled work hours.
• Additional Responsibilities: Performs other duties as assigned and supports the organization's quality program(s).

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

• Work Conditions:
  • Regularly required to sit, talk, and hear.
  • Frequently uses fingers for small movements like typing or picking up objects.
  • Occasionally required to walk, reach, stoop, kneel, crouch, or crawl.
  • Predominantly sedentary work (sitting most of the time).
  • Specific vision abilities include close vision, peripheral vision, depth perception, and the ability to adjust focus.
  • Movement within the facility is necessary to access equipment, documents, and attend meetings.
  • Lifting and carrying up to 10 lbs, occasionally up to 10-20 lbs.

Job Specifications:

Requirements:

• Experience: Claims and customer service experience is required. Experience working with providers and understanding office operations is beneficial but not essential.
• Language Skills: Spanish-speaking is a plus, though not mandatory.
• Citizenship: Must be a U.S. citizen.
• Shift: Must be able to work a set shift:
  • 8:00 AM to 4:30 PM EST or
  • 8:30 AM to 5:00 PM EST
• Duration: 90-day contract with the possibility of extension.
• Location: Remote position.
• IT Requirements: Candidates must meet the work-from-home IT requirements as specified by the supplier.
• Background Check: Successful completion of a background check through Sterling Managed Care Advisors.

Education:

• High School diploma or GED required; college courses preferred.

Experience:

• One (1) year of customer service and claims experience, or an equivalent combination of education and experience is required.
• Inbound call center experience is preferred.

Skills and Abilities:

• Knowledge of medical terminology and claims management.
• Strong oral and written communication skills.
• PC literate, including proficiency in Microsoft Office products.
• Analytical and interpretive skills.
• Excellent organizational skills.
• Strong interpersonal skills and the ability to interact with others professionally.
• Ability to multitask in a fast-paced environment.
• Ability to support multiple clients and utilize multiple systems simultaneously.
• Ability to work both independently and as part of a team.
• Ability to meet or exceed performance competencies.

Clearance:

• Credit security clearance, confirmed via a background credit check, is required.

Conditions of Employment:

Work Environment:

• The work environment typically involves the lighting, temperature, and noise of an open-floor plan office environment.
• Reasonable accommodations may be provided to enable individuals with disabilities to perform the essential functions.

This position demands a strong ability to manage claims, communicate effectively, and provide excellent customer service.