QualChoice of Arkansas
Position Title

Customer Service Representative

Job Title

Customer Service Representative

Job Description

General Summary

The Customer Service Representative is responsible for answering telephone inquiries of accounts, enrollees, and providers on matters pertaining to claims adjudication, enrollment, benefit interpretation, etc. Utilizes the telephone system equipment and the Health Claims Processing System, PBM systems, in performance of assigned tasks. The representative assumes responsibility for the timely and accurate processing of inquiries in accordance with corporate guidelines pertaining to coverage, payment, quality and productivity.

Principal Duties and Responsibilities

Accurate as well as timely documentation and resolution of inquiries pertaining to all types of medical services, i.e., professional, institutional, pharmacy, durable medical equipment, dental and vision.

* Notifying callers of resolutions via telephone and in writing when appropriate according to departmental turnaround standards.

* Responds to benefit questions for existing and prospective enrollees on all lines of business during open enrollment periods.

* Serves as an inter-departmental liaison identifying problems and helping to resolve them.

* Performs enrollment and benefit verification.

* Provides claims follow-up.

Handles walk-in inquiries as needed.

Maintains quality standards as determined by management.

Adheres to all company policies and federal and state privacy regulations in accordance with company training.

* Other duties as assigned.


Customer Service Representative I
Within 90 days of hire, must process a minimum of 40 queue/recovery calls per day with a Q/A rating of 95%

Job Knowledge, Skills and Abilities

Excellent written, interpersonal and verbal communication skills.
Sound analytical skills.
Must be able to type on a computer keyboard and use a 10-key calculator.

Expectations of all QualChoice Staff

Conducts business with high regard for corporate values and in compliance with its Code of Business Conduct.
Maintains high regard for member privacy and complies with information security and HIPAA policies.
Responsible for quality and continuous improvement within the job scope. Contributes to and supports the companys quality initiatives.
Accountable for all actions/responsibilities described in the companys policies and procedures as they relate to this position.

Work Environment/Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The work environment is a typical office environment.
The noise level in the work environment is usually moderate.
This is largely a sedentary role, requiring use of standard office equipment such as computers, phones, copiers/printers, and calculators.

Basic Qualifications

High school diploma or equivalent.
Two years of customer service experience gained through positions held in the health insurance industry and or medical claims processing.
Applicant must possess excellent grammar and soft skills in communicating over the telephone or in person.
Prefer knowledge of medical terminology, CPT and ICD coding.

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