Customer Service Claims Representative

Position Overview

The Customer Service Claims Representative provides high-quality service to internal and external customers while delivering an efficient and positive customer experience for routine lost-time claims.

This position is responsible for handling incoming communications from claimants, providers, clients, attorneys, and other parties, resolving claim-related questions and issues in accordance with established guidelines, policies, and procedures.

Work Arrangement & Schedule

• Work Arrangement: Remote
• Location Restriction: Candidates located in California cannot be considered.
• Time Zone: All shifts are listed in Central Standard Time (CST).
• A written agreement confirming the selected shift will be required from each worker.
• Candidate location and shift preference must be noted at the top of the resume.

Available Shifts

• 4x10 Schedule: Monday – Wednesday and Friday, 8:00 AM – 7:00 PM CST
• 5x8 Schedule: Monday – Friday, 10:30 AM – 7:00 PM CST
• 5x8 Schedule: Monday – Friday, 9:30 AM – 6:00 PM CST

Key Responsibilities

Customer Service & Claims Support

• Process incoming calls, faxes, and voicemails from:
  • Claimants
  • Providers
  • Clients
  • Attorneys
  • Other involved parties
• Resolve claim-related questions and issues in accordance with established guidelines and policies.
• Communicate claim status and current claim activity to clients and appropriate medical contacts.
• Respond to inquiries regarding jurisdiction-specific and claim-specific matters.
• Deliver high-quality service to both internal and external customers.

Claims Administration

• Enter information accurately into claims systems.
• Ensure claim files are properly documented.
• Verify that claims coding is accurate and complete.
• Coordinate claimant address updates and changes with appropriate internal departments.
• Maintain accurate and organized claim information.

Referrals & Coordination

• Provide referrals to appropriate resources, including:
  • Legal
  • Utilization Review
  • Pharmacy
  • Special Investigations Unit (SIU)
• Coordinate independent medical examinations as required.

Additional Responsibilities

• Support organizational quality programs.
• Perform additional duties as assigned.

Qualifications

Education

• High School Diploma or GED required.
• Associate degree from an accredited college or university preferred.
• Professional certification applicable to the line of business preferred.

Experience

• 2+ years of administrative and/or customer service experience required.
• An equivalent combination of education and experience may be considered.

Skills & Knowledge

• Excellent written and verbal communication skills.
• Proficiency with computers and Microsoft Office products.
• Strong investigative and organizational skills.
• Strong interpersonal skills.
• Ability to work effectively in a team environment.
• Ability to meet or exceed established performance competencies.
• Strong judgment and problem-solving abilities.
• Ability to analyze information and troubleshoot issues.
• Ability to manage multiple priorities simultaneously.
• Ability to work effectively under pressure and meet deadlines.
• Strong attention to detail and discretion when handling sensitive information.

Work Environment & Physical Requirements

• Ability to perform computer keyboarding for extended periods.
• Ability to communicate effectively through hearing, vision, and speaking.
• Ability to travel as required.
• Ability to handle work-related stress and multiple competing priorities.
• Reasonable accommodations may be provided when applicable and appropriate.