Quality Control Reviewer III

Responsibilities

• Conduct audits of Provider Relations call center inquiries via various systems (i.e. Vitech, QNXT, and Call Tracking)
• Communicate with providers, collection agencies, hospitals, doctors, dentists, lawyers, employers, and other professionals regarding health claims and other benefit inquiries; provide backup coverage to Telephone Representatives as needed
• Assist Supervisor in reviewing work of call center staff and redistribute errors; provides departmental training and side-by-side mentoring of staff
• Assist Telephone Representatives with difficult calls and resolve complex problems
• Investigate issues, provider advances and assist providers with claim payments or adjustments
• Work closely with various departments, insurance carriers and other agencies to resolve issues (i.e. Provider Relations, Claims, Finance, Eligibility and Coordination of Benefits)
• Review eligibility and claims systems for errors and call track and/or escalate inquiries for corrections or adjustments
• Review and monitor department call tracking folder, process call tracking inquiries, identify trends and troubleshoot problems
• Access web-based or report applications relevant to provider inquiries (i.e. ABF, iObserver, intranet, on-demand reports, or external provider websites)
• Review and search information using knowledge tool (i.e. BeneFAQs)
• Must meet departmental performance standards
• Perform additional duties and projects as assigned by management

• High School Diploma or GED required, some College or Degree preferred;
• Minimum two (2) years high volume call center experience as a Telephone Representative in a health plan or benefits environment required
• Comprehensive knowledge of eligibility, rules for extended or limited continuation of benefits (coordination of benefits, retiree extensions, enrollment)
• Comprehensive knowledge of health benefits such as: hospital, surgical, x-ray, laboratory, major medical, etc.
• Knowledge of 1199
  
  SEIU Fund benefits preferred (National Benefit Fund, Greater New York and Home Care Fund)
• Experience navigating web based applications and Call Tracking Systems (Vitech, QNXT, iObserver and IRIS)
• Excellent communication skills (written and verbal) and interpersonal skills; ability to maintain a pleasant attitude with providers to ensure customer satisfaction
• Able to work well under pressure, multi-task, establish priorities, meet deadlines, and follow up
• Strong ability to lead, mentor and motivate others, maintain professional manner and presentation
• Good problem solver and excellent analytical skills
• Call Center hours of operation are from 8:00 am until 6:00 pm; shifts are subject to change and/or availability
• Must meet attendance and punctuality standards