Claims Customer Service Representative - CA

JOB DESCRIPTION

Primarily responsible for the customer service process associated with workers compensation claims which includes servicing customers who contact us via the ACD phone line and supporting the claims management process for all claims teams across the Enterprise. Provides primary support for California jurisdictional claims. Acts as a back up to the claims intake process. Acts as a backup to the Service Center Business Development and Provider Relations teams on the ACD phone line.

Please note that this position has an end shift time of 6:00 pm.

• Inputs notes into medical bill review web-based system for disputes/denials.
• Manually produces claim welcome packets as requested.
• Researches outstanding checks for escheatment process and mails form letter to check recipient if applicable.
• Forwards travel documents back to sender requesting additional information.

Primarily responsible for the customer service process associated with workers compensation claims which includes servicing customers who contact us via the ACD phone line and supporting the claims management process for all claims teams across the Enterprise. Provides primary support for California jurisdictional claims. Acts as a back up to the claims intake process. Acts as a backup to the Service Center Business Development and Provider Relations teams on the ACD phone line.

Please note that this position has an end shift time of 6:00 pm.

• Inputs notes into medical bill review web-based system for disputes/denials.
• Manually produces claim welcome packets as requested.
• Researches outstanding checks for escheatment process and mails form letter to check recipient if applicable.
• Forwards travel documents back to sender requesting additional information.

(Brief bullet points detailing the major duties, not tasks, for this job and the % of time spent on each. Please list them in the order of importance).

• Supports the customer service work and processes for the Enterprise claims teams as well as the Subrogation Teams.
• Answers claim inquiries from policyholders, agents, injured workers, attorneys, pharmacies, medical providers for multiple jurisdictions for the Enterprise claims teams. Provides verification of claim status for multiple jurisdictions using multiple technology sources.
• Performs all facets of IME’s, AME’s, DDE’s, QME’s and any other independent type evaluation needed for the claim file.
• Provides backup as needed to Claims Document Analysts to review and analyze incoming documents and assign the appropriate document sub type to them.
• Reviews each document and adds pertinent information to the document keywords and to appropriate data fields in the claim system.
• Re-indexes and appropriately routes documents that have been assigned an improper document type or have been attached to an incorrect claim.
• Downloads electronic medical records from various vendors.
• Assists with the resolution of FROI errors.
• Adds legal matters and pertinent litigation information to the claim system upon receipt of legal documents.
• Reviews, researches, and properly routes all unidentified claims mail for all brands within the Enterprise.
• Provides backup to the Claims Processing Associates for review, research, and proper routing of priority unidentified claims mail for all brands within the Enterprise.
• Processes Claims Subpoenas. Performs all facets of the following referrals:
  Utilization review, Medical Management, Vocational Rehabilitation, Litigation, and all other Vendor Referrals as requested.
• Participates in projects to improve processing and workflow.
• Provides PPO, MPN, HCN provider names and/or general program information to customers
• Updates claim system with vital information changes.
• Updates document…