Service Rep OPL​/OPEIU

Company

Highmark Inc.

Provides quality customer service in a high volume contact center to include providing complete, accurate and timely responses to inquiries from subscribers, members, providers, internal and external customers; processes and adjusts claims.

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.

• 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.

• 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 over payments.
• Identifies potential opportunities, problems and concerns; recommends and forwards to Sr Service Representative and/or Management for review.

• 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.

• Assists with compiling data, charting of claims; provides necessary support to resolve cases.
• Assists with intermediary duties between vendor and corporation.

Performs all job duties efficiently, accurately and at an acceptable level of performance.

Performs related clerical duties: files, faxes, copies documents.

Maintains confidentiality and adheres to HIPAA regulations.

Delivers customer service in a professional, polite and efficient manner.

Performs other duties of a similar nature that are not inconsistent with this position or pay grade.

Required

Education:

HS/GED

Required Experience:

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 is required. Two (2) years Customer Service related experience in a high volume call/contact…