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Call Center and Claims Representative - REMOTE JOB, Full-Time



Full Job Description

Humana/iCare is seeking a Call Center and Claims Representative to join the growing Wisconsin Medicaid Market team.

The Call Center and Claims Representative meets the needs of members, potential enrollees and providers by providing a resource by phone to answer inquiries related to benefits, eligibility, claims, and perform other duties as assigned. Share your talents and develop your skills all while doing your part to improve the lives of others.


The Call Center and Claims Representative works in a call center setting and provides program, benefit, eligibility, and claims information and describes iCare services to existing, potential and new members via telephone and in writing. This role will also provide responses to provider claim inquiries within the designated timeframes, including claims status, denials, reconsiderations, and explanation of payments.

Essential Duties and Responsibilities

  • Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer (member or provider) requests and questions are handled appropriately and in a timely manner.

  • Provides support, guidance, direction & limited education to providers on member eligibility, authorizations, iCare guidelines and provider portal.

  • Provides limited authorization information of referrals to providers and members.

  • Research issues and uses judgment for obtaining relevant information.

  • Documents member information, including demographics and contacts made with customers within the Trizetto Call Tracking system.

  • Consistently meets individual performance and quality goals.

  • Adheres to Company policy guidelines.

  • Actively participates in department / company meetings.

  • Volunteers to participate in iCare community programs /events based on management approval.

  • Manages complaints / grievances / appeals and route appropriately for research and resolution.

Required Qualifications

  • 1 year of demonstrated customer service experience in a call center setting.

  • 1 year of experience in health insurance.

  • Experience in customer service business practices.

  • Strong interpersonal skills and ability to work effectively with persons with disabilities and a wide variety of ethnic, cultural, and socio-economic backgrounds.

  • Possess knowledge and experience of appropriate telephone skills.

  • Experience in the use of a personal computer and software applications, including Microsoft Windows and Microsoft Office Products.

  • Effective verbal and written communication skills.

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.

  • Satellite, cellular and microwave connection can be used only if approved by leadership.

  • Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

  • Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

  • Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Preferred Qualifications

  • Previous experience in Medicaid and/or Medicare, customer service and/or claims processing.

  • Bi-lingual in Spanish.

  • Previous experience working in a managed health care setting.

Scheduled Weekly Hours 40


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