Service / Claims Rep FEP / OPEIU

About the role

This position serves as a frontline contact for Highmark Inc., handling inquiries and claims for subscribers, members, providers, and other departments. It involves responding to and resolving customer questions, coordinating with internal and external entities, and managing claims.

Responsibilities

• 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 manner.
• 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.
• Pursues, researches, tracks, and follows up on information regarding claim benefits, eligibility, and all other aspects of business.
• 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 investigations 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 Senior Service Representatives and/or Management for review.
• 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.
• Researches and compiles information pertaining to all potential subrogation cases and forwards to vendors.
• Aids in compiling data, charting of claims; provides necessary support to resolve cases.
• Aids in intermediary duties between vendor and corporation.
• Performs all job duties efficiently, accurately, and at an acceptable level of performance.
• Filings, faxes, copies documents.
• Maintains confidentiality and adheres to HIPAA regulations.
• Delivers customer service in a professional, polite, and efficient manner.
• Performs related clerical duties.
• Performs other duties of a similar nature that are not inconsistent with this position or pay grade.

Requirements

• HS/GED with two (2) years of customer service related experience in a high volume call/contact center.
• One year of 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.
• Proficiency in English language skills, including spelling, punctuation, and grammar, in both written and verbal communication.
• 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.
• Problem solving: Identifies problems and inconsistencies; recognizes major issues, identifies key facts; seeks information.

Qualifications

• Must meet qualifications to perform the job including satisfactory completion of all training and testing Customer Service Representative tests – passing score.
• Well organized with ability to adapt to changing office environment; exhibits attention to details and time management skills.
• 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.
• Problem solving: Identifies problems and inconsistencies; recognizes major issues, identifies key facts; seeks information.

Skills

• Ability to multitask in fast-paced environment.
• Effective communication in both written and verbal communication with internal and external contacts, in a professional manner.
• 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.
• 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.
• Problem solving: Identifies problems and inconsistencies; recognizes major issues, identifies key facts; seeks information.

Benefits

N/A

Pay

$22.81 The starting hourly rate for this position listed above is for new employees. This rate has been established by the Local 153, Office and Professional Employee International Union (OPEIU) collective bargaining agreement (CBA) and is non-negotiable. If the successful candidate is currently a bargaining unit member of the OPEIU, hourly rate is commensurate with their anniversary year and pay grade as per the CBA.

Schedule

N/A