Document Service Representative 1

Summary Description: The Document Service Representative shall assume full responsibility for the completion of the necessary activities related to the processing of incoming mail for the entire organization, as well as the timely and accurate facilitation and handling of all incoming paper claim and correspondence documents. All tasks are performed on-site. This includes performing a detailed mail sort, batch preparation, and scanning of all incoming claims and correspondence to facilitate and ensure compliance with all New York State regulations, including prompt pay and to ensure accurate image routing to the appropriate business area to support customer service levels. Ownership is assumed for all aspects of claims examining and data entry on the FormWorks system, utilizing and interpreting Desk Levels to accurately examine and data enter claims via OCR, Key from Image, and Key Entry. Required data elements as defined by each business area must be accurately captured in accordance with departmental Desk Levels, ensuring images are filed appropriately in Macess and work items are routed to the correct doc flo queue for handling by each business area. The Document Service Representative will work closely with Member Services, Provider Services, Claims Operations, and Medical Affairs to resolve claims examining and correspondence data entry issues. The Document Service Representative will also be required to successfully apply problem solving and time management methodology to balance multiple tasks as business needs arise while maintaining production and quality standards. Essential Resource Responsibilities / Accountabilities: Examine, data enter and re-write all physician, hospital, dental, and pharmacy claims utilizing established policies and procedures as well as medical claims coding guidelines. Perform accurate FormWorks OCR error correction, Key from Image, and Key Entry on all medical, hospital, dental, and vision claims in accordance with departmental desk levels Perform accurate FormWorks data entry on correspondence documents in accordance with departmental desk levels to ensure work items are filed appropriately in Macess and work items are routed to the correct doc flo queue for handling by each business area Report any scanning, data entry, or workflow issues to the Team Lead, Document Management and/or a member of management as appropriate. Work mandatory overtime when deemed necessary to meet TAT service level metrics Report any obvious provider billing problems observed Provide value-added feedback regarding established desk levels and train newly hired staff when required. Maintain the production and accuracy ratio as established by the department Re-direct claims and correspondence to the appropriate resource/department as needed in accordance with established Desk Levels Research and contact appropriate resources as warranted for information necessary for the completion of examining and/or data entry utilizing the corporate documentation system Initiate and assist in the development of process improvements necessary to resolve claims examining and data entry issues and system limitations Perform all scanning room functions, this includes but is not limited to sorting, prepping, and scanning of all claims and correspondence documents into FormWorks in accordance with established desk levels Archive all incoming claim and correspondence documents in accordance with established Desk Levels Complete the daily rejection report, including retrieval of archived claim and correspondence documents, within established time frames Verify scanned documents for completeness Report any system, filing, scanning, or workflow issues to the Team Lead, Document Management, and/or a member of management as appropriate Perform general scanner maintenance as needed. Identify and report deviations in provider practice and billing to the Team Lead, Document Management Complete required department documents in an accurate and timely fashion as outlined in established procedures The employee agrees to comply with company's Corporate Compliance Policy, and all laws, rules, regulations and standards of conduct relating to the Corporate Compliance Policy and has a duty and obligation to report any suspected violations of any law, the standards of conduct or Corporate Compliance Policy to his or her immediate Supervisor, the fraud and abuse hotline, the Compliance Officer, the Compliance Director, Human Capital Management or the Chief Executive Officer. Performs other duties as assigned. Minimum Resource Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. EDUCATION (Please choose one (1) box highlighting the minimum educational level required to successfully perform the job.) High school diploma or GED required.0Associates degree or two (2) years of equivalent experience required. Bachelor's degree or four (4) years of equivalent experience required.0Advanced degree preferred. EXPERIENCE Six (6) months alphanumeric data entry experience in a healthcare setting is required Minimum of (1) year claims examining procedural review experience utilizing CPT-4, HCPCS, and ICD-9 codes is highly preferred Experience with review, interpretation and scanning of correspondence from multiple sources is highly preferred Experience or working knowledge with an on-line data entry system, especially Macess EXP and FormWorks , Web key is highly preferred. A minimum of one year office experience with strong PC skills and Microsoft Windows is preferred. SKILLS & ABILITIES Demonstrated ability to determine, analyze, and solve problems related to claims examining, correspondence and data entry Ability to successfully apply problem solving and time management methodology and balance multiple tasks as business needs arise Ability to apply specialty claims handling and data entry Desk Levels with adherence to department turnaround time frames to ensure regulatory compliance Demonstrated ability to effectively communicate on both a verbal and written basis. Must utilize appropriate grammar, spelling, punctuation, and sentence structure in all written communications Strong attention to detail and ability to meet established quality and production standards while maintaining department turnaround time frames Ability to work independently with minimal supervision is required. Physical Requirements: Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer. Ability to travel across the Health Plan service region for meetings and/or trainings as needed.

Created: 2026-03-04