CSR II

Analyzes, evaluates, resolves and responds to customer/provider inquiries received via telephone, correspondence or in person involving a variety of claim/benefit issues under various product lines. Will direct the adjudication of claims/inquiries.

Conducts internal and external research to determine and request the data needed to handle inquiries from Subscribers, Beneficiaries, Accounts or Providers. Obtains needed external data. Analyzes and services various product lines in the area (i.e., Administrative, Facility, Professional, Special Programs, Medicare/Complementary). Provides servicing responses by telephone, handwritten/check-off letters, or by a typewritten, self-composed letter. Initiates status reports to the inquirer when delays occur in responding to an inquiry, as required. Follows department/corporate reporting requirements (i.e., PCRS, ICS, Special Surveys and Manual counts). Organizes work to meet National/Corporate/Department Production and Quality Standards. Reroutes misdirected inquiries. Evaluates and price/adjudicates claims/inquiries. Interacts with others inside and outside the organization to resolve the inquiry/claim related problems. Determines the dollar amount of additional payment and directs the issuance of a check. Influences customers to accept the reasonableness of decisions and actions. May assist less experienced Reps and handle unusual or complex inquiries, including irate calls as well as those inquiries that may have implications for the retention of a group/contract, or provider. Other duties may be assigned.

Qualifications

High school graduate or GED equivalent.

Two (2) years of related work experience in areas such as public/customer service, sales representatives, claims processing, membership enrollment and one (1) year of public contact in positions such as teaching, social service work, bank teller, medical assistant/office assistant.

Three (3) years of total related experience or in the absence of internal BCBSM experience, the following may apply: A total of three (3) years of related work experience in areas such as public/customer service, sales representative or claims processing (or Direct Billed & Support).

Eighteen (18) months as an Account Clerk IV in Group Billing/Direct Billed and Support Departments.

Demonstrated knowledge of policies, practices and procedures related to billing, or contract coverage or changes, or rating and eligibility requirements or claims processing.

Demonstrated ability to analyze data and resolve problems related to inquiry and claims processing.

Demonstrated command of all skills necessary for oral and written communications with Subscribers, Beneficiaries, Accounts or Providers, in a clear, concise and tactful manner.

Must be able to pass the Customer Service selection process.

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, protected veteran status or status as an individual with a disability.

Job

Operations

Primary Location

Detroit

Organization

Service Operations-7103

Schedule

Full-time

KLASC-UK-Non-Exempt-X408R