Job Description

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