The Customer Care Representative I
South Portland, ME.
WellPoint is the nations leading health benefits insurer and a Fortune Top 50 company. At WellPoint, we are dedicated to improving the lives of the people we serve and the health of our communities. WellPoint strives to be the most trusted choice for consumers and a leader in affordable quality care with an unyielding commitment to meeting the needs of our diverse customers.
Bring your expertise to our innovative, performance-focused culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.
The Customer Care Representative I:
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Functions on a learning curve to become fully proficient in all aspects of customer service, claims and/or membership issue resolution.
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Performs research and analysis, advocating on behalf of customers through whole case methods.
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Learns to provide full service to members, providers, group administrators, and brokers by processing health care claims, handling inquiries, and/or performing membership functions.
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Performs at least two of the three functions routinely.
Primary duties may include, but are not limited to:
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Receives inbound telephone calls or paper and electronic claims from members and providers.
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Resolves issues for members, providers, group administrators and brokers.
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Analyzes the situation and completes research to ensure no rework or follow-up issues.
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Applies knowledge of policies and procedures, products, legislation and claims workflow.
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Interacts with systems to ensure claims are paid or denied based on terms of contract.
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Initiates interaction with other areas to ensure claims are handled properly and thoroughly.
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Interprets claims to determine primary or secondary liability and recognize when additional information is needed.
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Makes decisions on claims payment while considering benefit status, provider status, and impact on Wellpoint, the provider and the member.