Claims Customer Service Representative

Who We Are

PACE by IIH is empowering senior participants to age at home with dignity through personalized, comprehensive care plans that deliver high-quality health and human services along with strong community support. Through an interdisciplinary and participant-centered model of care, PACE by IIH is committed to improving quality of life, promoting independence, and providing compassionate support tailored to the unique needs of each participant. Our team works collaboratively to deliver innovative, community-based healthcare solutions that allow seniors to remain safely and comfortably in their homes while receiving the care and services they need to thrive.

Benefits

• 401(k)
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid sick time
• Paid time off
• Referral program
• Retirement plan
• Vision insurance

Job Summary

The Claims Customer Service Representative (CCSR) serves as a critical liaison between Innovative Integrated Health, Inc. (Company) and external healthcare providers (Providers). The CCSR handles incoming inquiries from Providers who submit claims to the Company.  The CCSR is expected to act with a high level of professionalism, confidentiality, and efficiency.  The role requires excellent judgment, strong communication skills, and the ability to manage multiple priorities in a fast-paced environment.  The CSSR is expected to demonstrate a high level of accuracy and attention to detail while upholding regulatory and privacy standards as mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Essential Job Functions
Duties include, but are not limited to:

• Respond to Provider inquiries regarding medical and dental claims via phone and email.
• Research and resolve issues related to claims status, denials, and payment discrepancies.
• Maintain up-to-date knowledge of benefit plans, claim adjudication guidelines, coding requirements, and HIPAA regulations.
• Accurately document all interactions and claim actions in the Company system by compliance standards.
• Maintain accurate records of interactions and claim resolutions.
• Communicate complex benefit details in a clear and concise manner to Providers.
• Collaborate with internal departments to facilitate resolution of claims-related issues.
• Recommend process improvements to enhance service delivery and improve Provider experience.
• Provide empathetic and efficient service to when working with Providers.
• Ensure all duties are completed with a focus on quality, compliance, and Provider satisfaction.
• Maintain punctuality, professionalism, and adherence to company policies and attendance requirements.
• Attend and participate in audits, staff meetings, in-services, and other projects as assigned.
• Adhere to and support the center’s practices, procedures, and policies including assigned break times and attendance.
• Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
• Flexibility to adjust schedule as needed to meet operational demands.

Knowledge, Skills and Abilities

• Proficient in Microsoft Office (Excel, Outlook, Word); knowledge of claims processing software, preferred.
• Familiarity with medical billing terminology (ICD-10, CPT, HCPCS) and Explanation of Payments (EOPs).
• Strong oral and written communication skills.
• Proven ability to multi-task and remain detail-oriented under pressure.
• Strong interpersonal and problem-solving skills; collaborative mindset.
• Ability to learn and apply regulatory requirements quickly.

Working Conditions and Physical Demands
The working conditions and 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.

• Ability to access all areas of the center throughout the workday.
• Ability to lift a minimum of 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance of another employee when attempting to lift or transfer objects over 50 pounds.
• Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching forward and overhead; squatting and knee…