Service Rep OPL / OPEIU

Company :
Highmark Inc. Job Description :
Job Summary

Provides quality customer service in a high volume contact center to include providing complete, accurate and timely responses to inquires 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.

Duties Note: The following is not intended to be an exhaustive list of all duties required of this position.
ADA

E1. Responds to and resolves inquires 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.

E2. Pursues, researches, tracks and follows up on information regarding claim benefits, eligibility and all other aspects of business:

•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 overpayments.

•Identifies potential opportunities, problems and concerns; recommends and forwards to Sr Service Representative and/or Management for review.
E3. 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.
E4. Researches and compiles information pertaining to all potential subrogation cases and forwards to vendor:

•Assists with compiling data, charting of claims; provides necessary support to resolve cases.

•Assists with intermediary duties between vendor and corporation.
E5. Performs all job duties efficiently, accurately and at an acceptable level of performance.
N6. Performs related clerical duties:
•Files, faxes, copies