Call Center Rep


Call Center and Customer Service

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Branch Information

Mount Vernon, IL - (USA) 4111 N Water Tower Pl Suite D IL Mt Vernon , IL 62864

Branch Phone Number


Job Description

Job Summary: Process all Military and Veterans Health (MVH) claims from receipt through resolution in accordance with MVH regulations, guidelines, and quality standards, with expertise in coordination of benefits (COB), eligibility, and claims development. Job Responsibilities This section explains the what, how and why of the position.

▪ Analyze claims to determine if eligibility requirements and claim filing requirements are met and make determinations.

▪ Calculate multiple Other Health Insurance (OHI) COB amounts using data from claims, such as the EOB or prior payment information given. Identify when to pend to other departments based on guidelines.

▪ Process all claim types by determining corrective action to be taken on various types of errors pended by system and resolving interactive edits.

▪ Process beneficiary-submitted claims.

▪ Process the highest priority claims from Customer Service.

▪ Translate, research, and verify claim information to determine if all requirements have been met.

▪ Review submitted claim information and select correct procedure code and diagnosis code using ICD-9, ICD-10, CPT4, and HCPCS manuals.

▪ Deal tactfully with people in a wide variety of situations to convey a favorable corporate image.

▪ Adjudicate specialty claims, including, but not limited to, pharmacy, ambulatory surgery, skilled nursing, dental, anesthesia, medical assistance, reprocessed claims, duplicate claims, ambulance, durable medical equipment (DME), or institutional based charges.▪ Write letters to providers and beneficiaries for missing claim information to process claim through.