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Claims Service Representative

Miami, FL · Administrative
Claims Service Representative - Managed Care
Miami, FL
*** This is a Full-Time, Benefits Available, CONTRACT opportunity,
expected to last 3 months or more!! ***

Claims Service (Inbound + Outbound Calls) Job Summary:
  • Serve as patient advocate working with Health Plan members and their health care providers to bring resolution to balance bills that members receive once their Health Plan has made payment to the provider. 
  • Demonstrate consistent ability to act independently within the scope of duties/responsibilities and ensure appropriate resolution to all claims inquiries and issues
  • Respond to inbound calls from health plan members and providers regarding balance bills and take appropriate action to resolve
  • Make outbound calls to health plan members and providers regarding balance bills and take appropriate action to resolve
  • Educate members and providers on Health Plan and Plan payment methodology
  • Work with providers in effort to gain their acceptance of the Health Plan reimbursement methodology
  • Generate provider balance bill letters and correspondence
  • Negotiate with providers within parameters/guidelines of the Health Plan
  • Assure the confidentiality of calls and documents
  • Document all calls in the Patient Advocacy system
  • Liaison with TPA claims Staff
Claims Service Background: 
  • Requires an education level of at least a high school diploma or GED.
  • Requires 2-3 years Healthcare/Insurance Industry experience in claims or billing / collections.
  • Ability to multi-task duties as well as the ability to understand multiple products and multiple levels of benefits within each product.
  • Knowledge of health care delivery system, Medicaid/Medicare and related state programs is a significant plus.
  • Computer skills to include Microsoft Word, Excel and basic data entry, including the ability to learn new and complex computer system applications.
  • Must test at a minimum of 35-45 wpm typing with a high level of accuracy.
  • Basic computer literacy (MS Office) and typing skills are necessary.
  • Bilingual in English and Spanish (or other languages beneficial to local population) is a plus.
Renan Villafuerte
Search Consultant
480-576-2316 (CALL – TEXT – FAX)
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