Job Description

Required Skills & Experience

- Bachelor’s Degree in Healthcare, Math, Engineering or related field, or equivalent work experience

- Minimum of four (4) years of claims processing

- Minimum of four (4) years in heavy call center required

- Learn various software applications and become self-sufficient in using the software in a user interface environment

- Quickly learn and apply new tools, processes, and standards

- Demonstrate adaptability and forward-thinking in the face of technological or organizational change

- Strong analytical and interpersonal skills

- Proficient with Microsoft products, including Word, Excel and Outlook

- Excellent customer service and telephone skills

- Individual must be reliable, dependable, and punctual

- Ability to balance and prioritize multiple tasks

- Ability to work in an environment with fluctuating workloads

- Ability to effectively balance workload in a fast-paced work environment

- Excellent verbal and written communication skills

- Ability to solve problems systematically, using sound business judgment

- Ability to make decisions with every call and handle escalated issues

- Knowledge of medical terminology

- Ability to research and verify claims payment, benefits, and eligibility issues

- Strong knowledge of benefits plans, policies and procedures

- Demonstrates organization and time management skills

Job Description

This role is customer facing and is considered a key customer service representative for the Health Fund. The Senior Participant Service Specialist/Analyst will process health insurance claims and answers calls from the customer (participant, providers, physicians, hospitals etc.) Adhere to eligibility, claims and call policies and procedures while making sound claim/call decisions. Foster strong relationships through the resolution of customer incoming call requests. Serve our customers by determining requirements, answering inquiries, resolving problems, fulfilling requests and maintaining key performance measures. Build strong working relationships with others within the company by demonstrating effective people skills and interpersonal savviness.

Essential Job Functions:

- Meet all key performance indicators established for this position in the areas of: efficiency, accuracy, quality, productivity, system adherence, customer satisfaction and attendance

- Elevate and enhance the Health Funds reputation by providing “World Class Customer Service”

- Answer incoming phone calls from customers and identify the type of assistance the customer needs (e.g. benefit and eligibility, billing and payment inquiries, authorizations for treatment and explanation of benefits (EOBs))

- Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in real-time

- Communicate and collaborate with customer to resolve issues, using clear, simple language to ensure understanding

- Fulfill requests by clarifying desired information; forward requests and follow through on all customer commitments

- Resolve problems by interpreting and clarifying issues; researching and exploring answers and alternative solutions; implementing solutions; addressing unresolved problems

- Review and research incoming healthcare claims by navigating multiple computer systems and platforms and verify the data/information necessary for processing (e.g. pricing, prior authorizations, and applicable benefits)

- Go the extra mile to engage customers

- Ensure that the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, grievance procedures, federal mandates, CMS/Medicare guidelines, and benefit plan documents/certificates)

- Train and coach new staff

Analysis Function:

- Analyzes existing business procedure documentation to identify content gaps or inconsistencies and prepares new or updated documentation, flowcharts, processes and procedures

- Assesses business processes and identifies opportunities for improvement

- Evaluates and prepares for expected changes in software applications or regulatory mandates across business processes and procedures

- Conducts research and analysis of historical, current and future benefit trends, service improvements and impacts to fund

- Identifies internal control weaknesses and makes recommendations for improvements

- Maintains and develops a detailed library of policies and procedures including new or updated documentation, flowcharts, policies and procedures

- Works with Team to conduct analysis focused on improving business process flow and customer issue resolution

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Employees in this role will enjoy a comprehensive benefits package starting on day one of

employment, including options for medical, dental, and vision insurance. Eligibility to enroll in

the 401(k) retirement plan begins after 90 days of employment. Additionally, employees in this

role will have access to paid sick leave and other paid time off benefits as required under the

applicable law of the worksite location.

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