Representative, Claims Customer Service

Job ID


Responsible for answering incoming calls from providers and members as they relate to eligibility, benefits, coverage, retro review and claims. This position will also problem-solve and explain programs and procedures to callers and will answer/address claim payment questions with providers, while following fundamentals of HIPAA compliance rules and regulations.



  1. Responds to telephone inquiries regarding claim status including payment, eligibility, coordination of benefits and retro-review status.
  2. Follows up on outbound calls and open system tickets
  3. Processes requests for claims, check tracers, and copies of EOBs.
  4. Maintains email communication with providers
  5. Participates in training sessions and departmental meetings as required
  6. Document all calls handled in system.


  1. High School graduate or equivalent.
  2. Minimum 1-2 years in managed care provider services or call center environment.
  3. Education and training and/or experience necessary to perform duties and position.


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