Customer Service Rep II

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Job Summary

This Position Is Responsible For Providing Assistance To Providers And Indian Health Services (Ihs). This Position Researches, Analyzes, And Responds To Telephone And Written Inquiries Related To Claims Issues, Pricing Issues, And Coordination Of Benefits. This Position Is Also Responsible For Resolution Of Inquiries, Including Adjustments And Making Recommendations Regarding Process Improvements. This Position Is A Subject Matter Expert In Regard To Projects And Testing. This Position Also Works Closely With The Ihs Customer And Acts As A Liaison Between The Provider And Ihs.

Responsibilities

1.Identify and interpret various plan documents for determination of application benefits and limits, requiring a current working knowledge of governing federal laws and insurance regulations, benefit plans and Blue Choice policies. Attain knowledge of eligibility, billing, stop loss and proposals.

2.Research, resolve and respond in an accurate, timely and courteous manner to inquiries and requests from brokers, marketing personnel, plan holders, employees, providers by telephone or written correspondence. Establish and maintain a favorable working relationship with the planholders and member employees.

3.Process claims and verify the accuracy of entry and payment which requires a thorough knowledge of medical and dental terminology; coding including ICD-9, CPT-4 and ADA; ability to determine UCR, pre-existing conditions, non-duplication/coordination of benefits, subrogation of benefits and current Medicare regulations, PPO discounts, network vs. out-of-network benefits.

4.Request additional information for incomplete claims received by generating automated system letters, by written correspondence or by telephone, requiring effective communication skills in dealing with planholders, employees, providers, billing area, pre-certification personnel and other company related personnel.

5.Report and coordinate changes to employee's eligibility record with Eligibility area, ensuring accuracy of the eligibility record.

6.Maintain courteous, responsiveness, timeliness and accuracy standards/guidelines set forth by the teams. Work with team inquiry members to meet.

7.Maintain aging reports. Send periodic follow up requests on information requested to assure claims are processed in a timely manner.

8.Enter inquiries into inquiry tracking system. Follow up to ensure timely completion.

9.Process adjustments to previously processed claims, as needed or requested, in an accurate and timely manner. Request refunds or stop-pay/reissues as required. Communicate disposition to the requestor. Research and respond to requests for consideration.

10.Prepare file summaries and replies for claims involving insurance commissioner complaint letters, letters from attorneys and claims to be submitted to reinsurance carriers. Refer immediately to the superior for review.

11.Ensure our customers' requirements are met at all times by "Doing It Right The First Time."

12.Assist team members with other duties including claims process, new group enrollment and other duties as needed to attain team performance goals.

13.Communicate and interact effectively and professionally with co-workers, management, customers, etc.

14.Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.

15.Maintain complete confidentiality of company business.

16.Maintain communication with management regarding developments within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS:

* 1 year of experience processing medical and dental claims and accurately determining payment.

* Knowledge plan of benefits, policies, managed care processes and governing federal laws and insurance regulations.

* Ability to research claims for unbundling, duplicate charges, ineligible charges, eligibility problems, pre-existing conditions, subrogation, pre-certification, medical necessity, etc.

* Effective verbal and written communication.

* Effective interpersonal skills to relate to distressed or challenging callers capably and tactfully as well as interact cooperatively with team members.

* Strong work habits and organizational skills necessary to complete promised action on inquiries and meet team goals for speed of answer and low abandon rate, and maintain accurate records.

* Good judgment, tact and discretion needed to respond appropriately to inquiries while maintaining confidentially and professionalism.

Preference in filling vacancies is given to qualified Indian candidates in accordance with the Indian Preference Act of 1934 (title 25, USC Section 472)."

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HCSC Employment Statement:

HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.