AmeriHealth Caritas · 6 hours ago
Provider Claims Service Representative
Philadelphia, PA
Full-time
Onsite
Mid Level
4+ years expAmeriHealth Caritas is seeking a Provider Claims Service Representative to respond to customer needs in a professional manner. The role involves reviewing and adjudicating claims, serving as a Subject Matter Expert, and conducting training for staff.
Health CareInformation Technology
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 management staff to identify and resolve areas of non-compliance
Reviews and verifies quality audit reports
Reconciles audit discrepancies, corrects in system and make appropriate changes to avoid recurrence
Maintains thorough knowledge of claims process systems, its databases and subsystems
Responds to and resolves provider and health plan claim inquiries
Monitors and tracks aged, pended, and open reports to maintain timeliness in claims processing.Inputs claims into the system for appropriate tracking and processing
Documents file, as appropriate, to support payment decision
Serves as a Subject Matter Expert and conducts training as required
Conducts cross training to staff as required
Actively participates in user acceptance testing functions, such as test script development, testing and documentation of test results
Qualification
Required
Minimum 4 years' experience in claims and/or call center required
High School/GED 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 management staff to identify and resolve areas of non-compliance
Reviews and verifies quality audit reports
Reconciles audit discrepancies, corrects in system and make appropriate changes to avoid recurrence
Maintains thorough knowledge of claims process systems, its databases and subsystems
Responds to and resolves provider and health plan claim inquiries
Monitors and tracks aged, pended, and open reports to maintain timeliness in claims processing
Inputs claims into the system for appropriate tracking and processing
Documents file, as appropriate, to support payment decision
Serves as a Subject Matter Expert and conducts training as required
Actively participates in user acceptance testing functions, such as test script development, testing and documentation of test results
Preferred
Associate degree preferred; minimum 45 wpm typing preferred
Healthcare or Managed Care experience preferred
Working knowledge of PC apps in a windows based environment
Company
AmeriHealth Caritas
AmeriHealth Caritas is the health care solutions provider for those in most need and the chronically ill.
10001+ employees
H1B Sponsorship
AmeriHealth Caritas has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (18)
2024 (17)
2023 (12)
2022 (14)
2021 (4)
2020 (11)
Funding
Current Stage
Late StageLeadership Team
Kathleen Giblin
SVP Clinical Operations
Ash Hanson
Executive Vice President & Chief Human Resources Officer
Recent News
2025-11-06
The Philadelphia Inquirer
2025-10-02
2025-10-01
Company data provided by crunchbase