Customer Service Representative I

About The Company

PEHP Health & Benefits is a division of the Utah Retirement Systems that serves Utah’s public employees through high-quality and competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis. As a government entity, we embrace both a public mission and a commitment to creating customer value, excelling in the market, and improving healthcare. We offer a competitive salary with generous benefits, personal development in a positive team environment, and excellent work-life balance. For most jobs, remote work is available for 9 out of every 10 workdays.

Position Summary

Job Description: Plays a critical role in PEHP’s efforts to serve and create value for our members and providers by helping them understand benefits, avoid payment surprises, navigate healthcare complexity, resolve problems, and make good benefit decisions. Performs a variety of duties to handle incoming calls, faxes and emails regarding claims, eligibility, verification of benefits, limitations, exclusions, provider applications and contracts, Health Savings Accounts (HSA), Health Reimbursement Accounts (HRA), FLEX Spending Accounts, Healthy Utah and WeeCare programs, billings and payments, and website related questions, for all PEHP plans.

Essential Duties & Responsibilities

• Receives and responds to incoming phone calls from policy holders, claimants, providers, and representatives of other insurance companies.
• Quotes benefits and provides claim status.
• Responds to complex questions regarding eligibility for covered services, claims processing policy descriptions and interpretations, claim payment processes, appeals and prior authorization/pre-notification, coordination of benefits, enrollment eligibility, and billing and premium questions.
• Greets the public and meets with policyholders/claimants regarding medical and dental issues related to benefits, claims, and payment status.
• Responds to questions regarding claims process, policy descriptions and interpretations, payment process, eligible or covered service, billing and premium questions, and various other insurance related questions.
• Educates members and providers on website tools and navigation and assists with online changes and updates.
• Troubleshoots account issues including setup, password resets, along with other various website issues.
• Identifies erroneous claims adjudication, member enrollment, provider set up, prior authorization/pre-notification in a timely manner, including the processing of any research and correction requests.
• Makes outgoing phone calls to assist members and providers in submitting information necessary to assist in benefit utilization, claim processing, completion of preauthorization requests, and appeals.
• Provides walk-in clients with requested forms, publications, and other informational materials.
• Directs walk-in clients and visitors to proper office locations; apprises staff of appointment arrivals.
• Listens to client complaints, questions, etc., and mails any forms that are requested.
• Provides clerical/secretarial support to various departments with the collection of forms, premium payments, etc., advises members of premium obligation, verification forms, etc., and returns incomplete forms.
• Interprets PEHP policies for walk-in clients regarding pharmacy and medical medications to determine coverage for retail, mail-order, and specialty medications.
• Serves as a resource to help resolve pharmacy issues pertaining to pre-authorizations, appeals, eligibility, mail-order issues, benefit interpretation, coordination of benefits, and claims payments.
• Coordinates with the Pharmacy department as needed.
• Advises callers and walk-ins in the proper procedures related to claims processing, corrections, and appeals.
• Receives and responds to incoming faxes, Message Center messages, and emails.
• Utilizes a variety of computer resources and tools to obtain proper and accurate information related to specific questions.
• Documents benefit quotes and other information given to members and providers to serve as an accurate record of what was communicated.
• Maintains regular and reliable attendance.
• Maintains strict confidentiality.
• Performs other related duties as required.

Clinical Coordination of Benefits

• Researches and updates coordination of benefits information for policy holders/dependents with multiple insurance coverage.
• Corresponds with members to verify and confirm coordination of benefits information.
• Analyzes documentation and state/national coordination of benefits guidelines to accurately determine coordination of benefits order in a variety of complex situations.
• Provides written confirmation of Coordination of Benefits changes to policy holders based on updates and changes.
• Sends written requests for information to policy holders as necessary.
• Receives and responds to inbound phone calls from internal Customer Service Reps, other PEHP and URS departments, policy holders/dependents, providers, and representatives of other insurance companies regarding coordination of benefits issues and concerns.
• Makes outbound phone calls to policy holders, providers, and other insurance companies to verify coordination of benefits information.
• Calls members to determine out of state residency status at the request of the claims department.
• Provides walk-in customers with assistance in regard to coordination of benefits concerns and issues at the request of members.
• Reviews claims as requested by the claims department for Coordination of Benefits changes and updates.
• Notifies the appropriate departments of impacts when Coordination of Benefits changes/updates are made.
• Processes a high volume of inbound mail, faxes, emails, etc. to maintain a prompt turnaround of information and ensure the accuracy of claims and benefits.
• Analyzes a variety of reports to maintain current COB information on PEHP policy holders and identify future COB changes or issues in a timely manner.
• Prepares COB documentation for imaging.

Required Experience

• A High School Diploma and one (1) year of progressively responsible experience performing a variety of duties relating to customer service; OR an equivalent combination of education and experience.
• Specific experience in health insurance call centers, customer service, or claims adjudication, preferred.