Company :Highmark Inc.
Job Description :
Duties Note: The following is not intended to be an exhaustive list of all duties required of this position.
E1. Exhibits competency in all responsibilities/duties of the Service/Claims Representative.
E2. Mentors new and existing Service/Claims Representatives. •Mentors and provides guidance to Federal Employee Program staff; assists and answers questions. •Reinforces previously provided training.
E3. Responds to and resolves inquiries from subscribers, members, providers, facilities: •Communicates and interacts with customers in a written or verbal manner 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; communicates with internal and external customers. •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 chats or in writing; utilizes Letter Reference Guide (LRG) templates as necessary and FEP Direct templates •Takes ownership of problems and establishes relationships with all customers meeting all corporate guidelines •Demonstrates an ability to communicate complete benefits and requirements to the customer. •Prepares effective written documentation that substantiates and supports the filing of system trouble tickets and change requests.
E4. Keys, processes and adjusts claims: •Performs online transactions and/or adjustments using the Corporate Claims administration system and FepDirect system, while adhering to Corporate and FEP guidelines. •Determines claim disposition by reviewing correspondence, coordination of benefits (COB) information, and claim inquiry history; follows desk levels, standard operating procedures and COB guidelines. •Researches, tracks, and follows up on information regarding claim benefits, eligibility and all other aspects of business. •Updates appropriate systems to reflect accurate information.
E5. Identifies and resolves problems and inconsistencies: •Identifies potential problems and inconsistencies and forwards to other Sr. Service/Claims Representative and/or to Management for review. •Identifies potential fraud cases and forwards to Special Investigation Dept for further review.
E6. Performs all job duties efficiently, accurately and at an acceptable rate of performance
E7. Performs related clerical duties: •Faxes, copies documents.
E8. Maintains confidentiality and adheres to HIPAA regulations.
E9. Delivers customer service in a professional, polite and efficient manner.
N10. Performs other duties of similar nature that are necessary and not inconsistent with this position or this pay grade.
A minimum of 18 months of current consecutive experience as a Service Representative and/or Service/Claims Representative at BC/BS of WNY, within the past three (3) years. Must have achieved and maintained acceptable levels of productivity and quality measures for the previous 18 months.
1. Must meet qualifications to perform the job including satisfactory completion of all training and testing
2. Completion of Predictive Index Assessment
3. Ability to self direct and multitask in fast paced service environment
4. Possesses investigational and problem solving skills
5. Well organized with ability to adapt to changing office environment; exhibits attention to details and time management skills
6. Proficiency in English language skills, including spelling, punctuation and grammar, in both written and verbal communication to ensure communications are issued in a professional manner
7. Ability to effectively communicate (verbal, written and interpersonal communication) with internal and external contacts, in a professional manner.
8. Working knowledge of personal computer and application software such as Microsoft Office
9. Ability to utilize basic office equipment including personal computer, scanner, telephone, copier, printer, fax, calculator.
10. Computer Software typically used: Microsoft Word, Facets/Streamline, PEGA/PRPC, Content Manager, FepDirect
11. Must display and demonstrate Core Values and adherence to Company Office Rules
12. Maintains confidentiality and adheres to HIPPA regulations
13. Position requires an interview by a five (5) member interview panel consisting of two (2) members of Management, two (2) members of the Grievance Committee and one (1) Human Resources Representative. The designated representative of the HR department will have no decision making involvement unless the team does not reach consensus. Required knowledge and skills will be evaluated.
Identifies problems and inconsistencies; recognizes major issues, identifies key facts; Seeks information.
Does this Position have Supervisory Responsibility? No
Number of Emps Supervised:
Titles of Employees Supervised:
Other Job Specifications:
External Contacts: Subscribers, Members, Providers, other Blues plans, Federal Representatives
Working Conditions/Physical Demands:
* Must be able to work in an office environment
* Physical Effort: Minimum; typical of most office work. Mostly sedentary work.
* Weight: lift/carry/push/pull under 10 lbs.
* Prolonged Sitting
* Repetitive Motion
* Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
* Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
* Vision Req: Close vision (clear vision at 20 inches or less)
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )
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