Claims Service Representative

Company Highmark Inc. Job Summary Provides quality customer service within a high volume contact center to include providing complete, accurate and timely responses to inquiries from subscribers, members and providers; keys, processes and adjusts claims in accordance with the Service Benefit plan (Federal Employee contract). Eligibility & Location This is a bargaining unit position. The collective bargaining agreement for this position requires that candidates and employees reside in the following counties in the State of New York: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, or Wyoming . Duties Note The following is not intended to be an exhaustive list of all duties required of this position. Responsibilities E1. Responds to and resolves inquiries from subscribers, members, providers, facilities, groups, other plans and other departments: Communicates and interacts with internal and external customers in a clear, unambiguous, concise, professional and empathetic fashion. Handles all inquiries and services incoming and outbound calls and correspondence. Considers all aspects or elements in a logical manner; considers contractual provisions and options to resolve inquiry. Utilizes and interprets appropriate reference materials and other necessary resources in responding to inquiries. Communicates with internal and external customers via phone, personal contact (lobby walk-ins), email, online chat or in writing; utilizes Letter Reference Guide (LRG) templates as necessary. Takes ownership of problems and establishes relationships with customers meeting all corporate guidelines. Demonstrates an ability to communicate the contractual benefits and requirements to the customer; communicates pros and cons of various plan benefit differences. Coordinates with Marketing and Enrollment staff and other internal and external entities, including Medicare and Dept of Treasury, to resolve and respond to timely Medicare Secondary Payor (MSP) Demand Letters. E2. Pursues, researches, tracks and follows up on information regarding claim benefits, eligibility and all other aspects of business: Acts as frontline contact for company, identifies potential problems and inconsistencies and corrects to prevent ongoing or future problems. Builds files in COB module and Facets, updates systems to reflect accurate information. Identifies, researches and solicits information on possible Reverse Benefits After Termination (RBAT) cases; works with multiple areas to verify RBAT status, creates files and processes/adjusts claims related to positive RBAT cases. Conducts OPL investigation to include COB claims processing, adjustments, letter generations and building files in both the COB module and Facets. Addresses, researches and responds to NYS Insurance Department (NYSID) complaints. Researches, compiles case information to audit subscribers/ providers for overpayments. Identifies potential opportunities, problems and concerns; recommends and forwards to Sr Service Representative and/or Management for review. E3. Processes and adjusts claims for all lines of business: Performs online transactions and/or adjustments utilizing Corporate Claims administration system and ITS standard formats and procedures. Determines claim disposition by reviewing correspondence, coordination of benefits (COB) module, and claim inquiry history; follows desk levels, standard operating procedures and COB guidelines. Researches, prepares responses and provides supporting documentation. Identifies potential fraud cases and forwards to Special Investigations Unit. E4. Researches and compiles information pertaining to all potential subrogation cases and forwards to vendor: Assists with compiling data, charting of claims; provides necessary support to resolve cases. Assists with intermediary duties between vendor and corporation. E5. Performs all job duties efficiently, accurately and at an acceptable level of performance. E6. Performs related clerical duties: files, faxes, copies documents. E7. Maintains confidentiality and adheres to HIPAA regulations. E8. Delivers customer service in a professional, polite and efficient manner. E9. Performs other duties of a similar nature that are not inconsistent with this position or pay grade. Required Education / Experience HS/GED: Two (2) years customer service related experience in a high volume call/contact center. Preferred Education / Experience HS/GED: One year customer service, contact center, or healthcare related experience as demonstrated by proficiency in one or more of the following areas: claims processing, adjusting or membership processing. Required Knowledge / Skills Must meet qualifications to perform the job including satisfactory completion of all training and testing. Customer Service Representative tests – passing score. Ability to multitask in fast paced environment. Well organized with ability to adapt to changing office environment; exhibits attention to details and time management skills. Proficiency in English language skills, including spelling, punctuation and grammar, in both written and verbal communication to ensure communications are issued in a professional manner. Ability to effectively communicate in both written and verbal communication with internal and external contacts, in a professional manner. Working knowledge of personal computer and application software such as Microsoft Office. Ability to utilize basic office equipment including PC, scanner, telephone, copier, printer, fax, calculator. Computer Software typically used: Content Manager, Facets, PEGA, OnDemand. Required Licenses / Certifications Problem Solving Identifies problems and inconsistencies; recognizes major issues, identifies key facts, seeks information. Managerial / Supervisory Responsibilities Does this Position have Supervisory Responsibility? No External Contacts Customers, Members, Providers, Groups, other insurance plans. Working Conditions / Physical Demands Position requires: Must be able to work in an office environment. Position involves: Physical Effort: Minimum; typical of most office work. Mostly sedentary work. Weight: lift/carry/push/pull under 10 lbs. Prolonged Sitting. Repetitive Motion. Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc). Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks. Vision Req: Close vision (clear vision at 20 inches or less). Pay Rate $22.81 EEO Statement Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. #J-18808-Ljbffr