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
We are a company committed to creating inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity employer that believes everyone matters. Qualified candidates will receive consideration for employment opportunities without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, disability, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to Human Resources Request Form (https://airtable.com/app21VjYyxLDIX0ez/shrOg4IQS1J6dRiMo) . The EEOC "Know Your Rights" Poster is available here (https://www.eeoc.gov/sites/default/files/2023-06/22-088\EEOC\KnowYourRights6.12ScreenRdr.pdf) .
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Skills and Requirements
Bachelors 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 null
We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal employment opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment without regard to race, color, ethnicity, religion,sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military oruniformed service member status, or any other status or characteristic protected by applicable laws, regulations, andordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or the recruiting process, please send a request to HR@insightglobal.com.
