Claims Customer Service Representative

Job Description

We are seeking detail-oriented Claims Production Professionals to support accurate and timely medical claims processing. This role involves investigating, analyzing, and adjudicating claims while ensuring compliance with benefit contracts, company policies, and quality standards. The ideal candidate is analytical, adaptable, customer-focused, and able to balance productivity with accuracy in a fast-paced environment.

• Review, investigate, and process medical claims accurately and within established turnaround times.
• Apply benefit contracts, eligibility rules, pricing, and coordination of benefits to ensure proper claim adjudication.
• Research, correct, and reprocess claims as needed while maintaining complete documentation and audit trails.
• Respond to member, provider, and internal inquiries regarding claims and benefit applications.
• Ensure compliance with policies, privacy requirements, quality standards, and regulatory guidelines.
• Identify process improvement opportunities and contribute to operational efficiency initiatives.
• Utilize AI and automation tools responsibly to enhance productivity, documentation, and workflow organization while maintaining compliance and accuracy.

• Meet or exceed quality, productivity, accuracy, and timeliness standards.
• Independently manage multiple claim types and increasingly complex claims.
• Deliver excellent customer service and effective issue resolution.
• Demonstrate sound judgment, adaptability, and continuous improvement contributions.

• High school diploma or equivalent.
• Approximately 2 years of office experience, preferably in health insurance, healthcare administration, or a medical office setting.
• Proficiency in Microsoft Office (Word, Outlook, Excel).
• Strong data entry, analytical, mathematical, and problem-solving skills.
• Exceptional attention to detail and ability to meet productivity goals.
• Ability to learn multiple systems and work independently while collaborating within a team.

Within the first year, the successful candidate will consistently meet quality and productivity standards, accurately process a variety of claims with minimal supervision, provide excellent service to members and providers, adapt to changing priorities, and support continuous improvement efforts within Claims Operations.

Enterprise Health Insurance Co. Multi-State. Trusted health coverage, care, confidence, and support when it matters most.