Customer Service Representative
NAMM North America Medical Management - Ontario, CA

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Answer and respond to claim issues received from Customers via the telephone in a professional and efficient manner.

  • Respond to telephone inquiries related to professional and institutional claims processing in a professional manner while displaying empathy toward the callers concern.
  • Ability to interpret provider and health plan contracts to ensure accurate responses to calls
  • Forward issues, attaching all necessary documentation, to the appropriate internal departments to ensure the correction of inaccurately processed claims, i.e.; Appeals, UM, Claims, etc.
  • Log issues into the Customer Service Tracking database that require resolution and/or follow-up
  • Plan and organize workload to ensure efficient and timely resolution of issues.
  • Respond to callers with the resolution of issues in a timely manner in accordance with the guidelines set by the department
  • Follow and support the guidelines set by the department and organization to ensure overall goals are met
  • Maintain minimum standards for the department for quality and quantity of calls received
  • Update Customer Service Tracking database with the resolution of issues in a timely manner
  • Foster interpersonal relationships, showing empathy and understanding towards staff, protecting individual self-esteem. Understand own impact on others; interact effectively with peers, subordinates, and supervisors.
  • Any other assigned duties as delegated by the Customer Service Supervisor.

  • High school diploma or a general education degree.
  • Minimum of one to two years experience in Medicare and HMO claims processing
  • Working knowledge of CPT, ICD-9 Coding, medical terminology, and UB92 and HCFA 1500 claim formats
  • Working knowledge CMS (HCFA) and DMHC guidelines
  • Ability to interpret provider and health plan contracts
  • PC proficient in a windows environment
  • Good to excellent communication skills.
  • Strong organizational and prioritization skills.
  • Able to represent the Group Network and Claims Department in a positive manner.
  • Ability to retain composure in stressful situations.
  • Ability to identify confidentiality and its requirements. (HIPAA)
  • Strives to be a team player.
  • Ability to read with attention to detail.
  • Knowledge of standard billing practices.



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