The Customer Service Claims Specialist (CSCS) works in the MDwise call-center to serve as the initial and primary source of contact for all MDwise providers with claims inquiries to ensure they are handled or transferred in an efficient and effective manner. In addition to acting as the primary claims inquiry representative, the position acts as a liaison between members, network providers, external agencies, and MDwise.
Knowledge, Skills, and Abilities:
- Handle and/or refer claims inquiries from providers, the call center, and MDwise Delivery Systems based on pre-determined workflow.
- Refer claims disputes, EDI, and claim denials to the Claims Research Team or MDwise Delivery System according to the pre-determined workflow.
- Contribute to the development and maintenance of provider education tools relative to the MDwise claims process.
- Participate in regular scheduled Claims Research Team or special project meetings.
- Answer direct calls from providers, Delivery System Provider Relations staff, Care Managers, Quality Improvement staff, and/or Delivery System Administrators.
- Establish a strong working relationship with Claims department staff at the Delivery Systems and MDwise to enhance the provider experience.
- Provide prompt, courteous, and accurate responses to inquiries and concerns as defined by organizational standards.
- Educate providers on appropriate billing practices according to MDwise policies and procedures.
- Serve as the caller’s advocate to resolve outstanding issues.
- Recognize potential quality issues and process information accordingly.
- Document all contacts with providers in the appropriate system and update member information as appropriate.
- Support all Inbound/Outbound calls following appropriate MDwise policies and procedures.
- Establish a direct working relationship with Delivery System providers.
- Maintain confidentiality of all information to which there is access.
- Perform other duties as assigned.
Minimum Qualification, Training, and Experience:
- Ability to communicate effectively with health plan members, staff, healthcare providers and social service providers.
- Knowledge of ICD-CM and CPT coding guidelines.
- Knowledge of Medical Terminology and Physiology.
- Knowledge of Medicaid and Medicare guidelines.
- Ability to effectively and professionally communicate orally and in writing.
- Working knowledge of ACD telephone system.
- Demonstrated ability to compose responses to incoming e-mails from providers and Delivery System staff.
- Excellent listening skills.
- Ability to remain calm in stressful situations.
- Exceptional analytical skills to help ascertain how MDwise can best serve each caller.
- Ability to establish and maintain effective working relationships with members/clients, staff (to include Delivery System staff), management, providers, and the public.
- Excellent organizational skills.
- Excellent computer skills including keyboarding, Microsoft Excel, Microsoft Word, Microsoft Outlook, and the ability to learn additional databases/programs.
- Familiarity with individual Delivery System procedures and practices preferred.
- Minimum of a high school diploma; Certification, Associate or Bachelor’s degree preferred.
- Minimum 1-2 years of experience in Medical Coding and Billing strongly desired.
- Prior experience in the Health Insurance field preferred.
- Prior experience in call center setting strongly preferred.
MDwise, Inc - 8 months ago