Job Description

Job title: Service Advocate – Claims I

Location: Jacksonville, FL (Remote Okay)

Duration: 3 months

Job Description:

The role of Service Advocate is focused on servicing current or potential customers (which are defined as members, providers, agents, brokers, benefit administrators or benefits consultants). Incumbents resolve questions and issues, help the Company’s customers utilize products, tools and services and directly contribute to customer satisfaction and retention. Roles in the Service family perform activities related to the processing of claims; providing customer service/inquiry resolution; enrolling, billing and collecting payments from consumers and group accounts; ensuring quality management and improvements in related processes and ensuring customer service needs are met by forecasting, monitoring and adjusting call volumes and staffing requirements.

Roles in the Claims sub-family review and adjudicate claims; determine whether to return, deny or pay claims following policies and procedures; process subrogation, workers’ compensation and other claims where third party liability may exist; recover overpayments, and answer inquiries from other internal departments, insurance adjustors, attorneys and members.

Essential functions:

• Review and adjudicate high risk claims.
• Process credit listing functions, aged listings and held claims.
• Process adjustments by working with ambulance services, inpatient facility services, and others.
• Determine whether to return, deny or pay claims following contract benefit and organizational processing guidelines.
• Perform additional research to develop claims; includes contacting providers or members.
• Provide customer service and education to plan members and providers by answering more complex questions regarding insurance claims and policies, resolving issues and ensuring customers understand the Company’s products, services and processes. Calls are predominantly routine, but may require deviation from standard screens, scripts and procedures.
• Perform research to respond to inquiries and interpret policy provisions to determine most effective response.
• Use computerized systems for tracking, information gathering and troubleshooting.
• Actively seek, identify and implement process improvement opportunities.

Accountable for the oversight of PIO medical record documentation and/or itemized bills needed to perform PIO pre-payment claim billing reviews. Associates are responsible for requesting, tracking and triaging provider medical records and itemized bills throughout the various FL Blue systems and process touchpoints to ensure timely resolution of claim reviews and claims processing. This type of support is provided to the various PIO Pre-Payment review programs, such as High Risk, High Dollar, DRG reviews etc.

Essential Functions % TIME

The essential functions listed represent the major duties of this role, additional duties may be assigned.

• Search the various systems (e.g. PAIS, EIP, Seibel, Content Central) to locate medical records associated with PIO claims and/or request 25%
• Create PAIS medical record request letters to requests specific documents for PIO contested claims 15%
• Triage incoming medical records/itemized bills to the appropriate PIO area and/or the pre-pay claims UI 20%
• Chase outstanding medical record requests by; sending 2nd requests, contacting the provider via phone call to obtain requested medical records to ensure timely review and claim adjudication 25%
• Make provider phone calls to attempt to obtain the requested medical records 5%
• Monitor Seibel and Pre-Pay UI medical record inventories to meet departments goals 10%

Preferred Experience:

• Managing Claims records
• Strong customer service and ability to manage a high level of attention to detail
• Professional Communication over the phone when working with clients

Required Work Experience

• 0-1 years of related work experience or equivalent combination of transferable experience and education
• Strong customer service and ability to manage a high level of attention to detail
• Professional Communication when assisting clients/customers over the phone

Required Education

High school diploma or GED

How to Apply

Job Types: Temporary.

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