Telephone Representative II (Provider Relations)

Job Title

Responsibilities

Communicate with doctors, hospitals, and other professionals via telephone regarding 1199SEIU members, dependent eligibility for health benefits, claims, and other plan services

Verify and determine eligibility for members, spouses, dependents, including the reinstatement of terminated coverage

Research and request documentation for provider enrollment, credentialing and provider file updates

Research and provide schedule of allowance for procedure codes and prior authorization requirements, research check reconciliation of claim payments

Accurately and professionally respond to telephone inquiries regarding member benefits and claims

Examine dental, vision, hospital, and medical claim histories for claim status, accuracy and timeliness

Create call tracking records in call tracking system (QNXT) to the appropriate call tracking folders for resolution; mail printed materials upon request

Review call tracking items returned to individual folder for closure or assignment to correct call tracking folder as required

Assign claim inquiries, enrollment, and eligibility issues to appropriate call tracking folders for resolution

Generate call tracking inquiries for problems related to all of the above for correction

Advise providers of new programs, plan improvements and plan changes

Verify provider inquiry using Knowledge Tool (BeneFAQs, QNXT, DocFind, iObserver)

Retrieve and review scanned claim images using IRIS System

Perform additional duties and projects as assigned by management

Qualifications

High School Diploma or GED required; Some College or Degree preferred

Minimum two (2) years high volume customer service experience in a call center environment; or two (2) years health claims processing experience required

Keyboarding skills required (minimum 5,000 KPH and 80% accurate rate)

Experience using web-based applications, basic knowledge of health claims processing systems (QNXT, Vitech) and Fund eligibility requirements preferred (National Benefit Fund, Greater New York Fund, Home Care Fund); experience with Provider Relations a plus

Excellent written and verbal communication skills with great interpersonal skills

Ability to initiate own correspondence and maintain a pleasant attitude to ensure excellent service to members and providers

Ability to multi-task and work under pressure due to volume and urgent nature of calls

Call Center hours of operation are from 8:00 am - 6:00 pm; shifts are subject to change and/or availability