• TMSM COC
  • Phone Claim Analyst I (Sup Health) - Remote

    Posted: 07/31/2022

    Ensures the accurate, prompt, and thorough evaluation of claims by analyzing and determining the appropriate action steps needed while adhering to both internal and external regulations and ensuring an industry leading customer experience.

    Requires independent decision making on claims situations using some critical thinking. Claim analysis includes: eligibility determination for benefits based on information received, contract analysis, customer service, fraud detection and awareness, some financial calculations, interpreting information and adhering to all statutory/governmental regulations. This includes analyzing information received, and determining if additional information is needed to make an accurate benefits decision.

    Embraces the customer-focused strategy and demonstrates our shared values (Customer Focus, Integrity, Innovation, Accountability, and Collaboration) by providing effective customer service resulting in first request resolution and a positive customer experience.

    Interacts, responds and resolves customer claim requests via multiple channels which may include phone, email and written correspondence. Performs multiple work roles with basic knowledge and skill sets such as data entry, processing basic claim transactions and handling common customer requests under minimal supervision.

    WHAT YOU'LL DO:

    • Accurately determines claim benefits payable based on medical information and contract language in a timely and accurate manner.
    • Reviews and analyzes provider information to identify changes, additions and deletions. Verify all information conforms to established policies and procedures; ensure that provider data adheres to Corporate guidelines for file integrity and reporting purposes while maintaining production, quality and time service standards.
    • Analyzes claims documentation and correspondence in order to process claim transactions, or assists with customer requests to determine appropriate outcomes. Keys and documents data accurately.
    • Communicates with external and internal customers to obtain specific claim information in order to finalize claims and to explain claim handling.
    • Communicate with providers and internal departments to provide information in reconciling conflicting Tax Identification Number (TIN) and/or Legal Name responses.
    • Reviews and analyzes provider information to identify changes, additions and deletions. Verify all information conforms to established policies and procedures; ensure that provider data adheres to Corporate guidelines for file integrity and reporting purposes while maintaining production, quality and time service standards.
    • Receives, analyzes and processes routine incoming claim inquires, and communicates outcomes. Effectively responds to and resolves customer requests by utilizing knowledge and skill sets, systems, policies, procedures, regulations and other reference materials.
    • Identifies and investigates potential providers to ensure marking of the providers with accurate schedule identifiers to support claims adjudication.
    • Provides effective customer service via multiple channels such as phone (to include inbound and outbound calls), written/email correspondence, etc. Performs service recovery techniques to resolve requests. Provides compliant and easily understood resolution options with the desired outcome of creating a positive customer experience. Utilizes resources to support service delivery resulting in retaining and/or growing the business.
    • Meets and/or exceeds department standards related to attendance, productivity and quality
    • Creates written letters to provide concise explanations to customers regarding claim determinations.
    • Actively participates in self-development opportunities with a willingness to learn new skills and/or product lines.
    • Actively participates in daily management through huddle involvement and the identification and supports implementation of process improvements. Provides insights and recommendations for enhancements to processes, training and the quality of service delivery to our customers.
    • Has a primary focus on customer satisfaction, provides an effective level of customer service.
    • Stays abreast of and adheres to Company processes and procedures, industry changes, federal and state legislation and regulations.
    • May assist with the development, delivery and oversight of training and quality auditing program material.
    • Develops and maintains effective working relationships with internal and external customers.

    ABOUT YOU:

    • You help promote a culture of diversity and inclusion within the department and the larger organization. You value different ideas and opinions. You listen courageously and remain curious in all that you do.
    • You are able to work remotely and have access to high-speed internet, 150MBPS
    • Must be located in United States or Puerto Rico
    • Shows a sense of urgency and is accountable for work results.
    • Ability to adapt to a diverse and changing work environment. Willingness to learn new skills with the ability to multi-task.
    • Ability to work independently, and/or as part of a team, in a collaborative environment and is approachable.
    • Effective time management and organizational skills with an attention to detail and analytical and decision-making abilities.
    • Ability to meet deadlines in a fast paced work environment
    • Effective oral, written and interpersonal communication skills, sound judgment and the ability to think within a structured and compliant work environment while focusing on the customer.
    • Working understanding of computer systems such as email, data entry, and Microsoft products, with proficient keyboarding skills.
    • Ability to work flexible shifts and maintain regular and predictable attendance with adherence to department and company attendance expectations. May be required to work overtime based on business needs.
    • Ability to assess and understand the needs of the customer and demonstrates flexibility in customizing approach and response to resolve requests in a respectful and timely manner.

    VALUABLE EXPERIENCE:

    • High school diploma or work equivalent.
    • Insurance product knowledge.
    • Experience with the application of policies, practices and procedures in a business environment.
    • Knowledge of medical terminology.

    WHAT WE CAN OFFER YOU:

    • A diverse workplace where associates feel a sense of belonging. To learn more about our commitment of Diversity, Equity and Inclusion, please visit our website
    • An organization that feels like a small, close-knit community and has the strength of a Fortune 500 company.
    • Tuition reimbursement, training and career development.
    • Comprehensive benefits plan that includes medical, dental, vision, disability and life insurance.
    • Flexible spending accounts for healthcare and childcare needs.
    • 401(k) plan with a 2% company contribution and 6% company match.
    • Competitive pay with an opportunity for incentives for all associates.
    • Flexible work schedules with a healthy amount of paid time off.
    • For more information regarding available benefits, please visit our Career Site.
    • Salary Range: $19.00/hour
    • Pay commensurate with experience.
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