Customer Care Representative I - Multi - 42180 - South Portland, ME. 12/14

South Portland, ME

WellPoint

• Functions on a learning curve to become fully proficient in all aspects of customer service, claims and/or membership issue resolution.
• Performs research and analysis, advocating on behalf of customers through whole case methods.
• Learns to provide full service to members, providers, group administrators, and brokers by processing health care claims, handling inquiries, and/or performing membership functions.
• Performs at least two of the three functions routinely.

• Receives inbound telephone calls or paper and electronic claims from members and providers.
• Resolves issues for members, providers, group administrators and brokers.
• Analyzes the situation and completes research to ensure no rework or follow-up issues.
• Applies knowledge of policies and procedures, products, legislation and claims workflow.
• Interacts with systems to ensure claims are paid or denied based on terms of contract.
• Initiates interaction with other areas to ensure claims are handled properly and thoroughly.
• Interprets claims to determine primary or secondary liability and recognize when additional information is needed.
• Makes decisions on claims payment while considering benefit status, provider status, and impact on Wellpoint, the provider and the member.