**Responsibilities:**

Under the general direction of the Operations Call Center Supervisor, responsible for responding in a timely, professional and courteous manner to all customer needs. This includes provider phone calls or correspondence regarding benefit, eligibility, and other provider issues. Reviews and adjudicates claims based on provider and healthplan contractual agreements and claims processing guidelines. Serves as a Subject Matter Expert. Conducts cross training to staff as required. Demonstrates solid knowledge of Provider Service/Claim systems, functions and team process. Demonstrates superior skill in dealing with provider issues/inquiries, team members, and co-workers.

+ Suspends claims requiring additional information and/or special handling; initiates action to obtain required information.
+ Forwards claims requiring external department intervention to the appropriate department or person.
+ Monitors outstanding inquiries and works with ...