Job Description :
This role provides new and existing customers with the best possible service related to help desk inquiries, service requests, billing inquiries and other customer requests. Determines whether to return, deny or pay claims following organizational policies and procedures. Provides direction on corrective actions needed including but not limited to processed claims, using enrollment, benefit and historical claim processing information. This job will perform post-payment reviews and advise on corrective adjustments as deemed appropriate. This role will work across the enterprise to partner with key functions, including Health Plan Operations (HPO), provider contracting, provider audit, and other key implementation stakeholders, and may support multiple health plan clients.
- Respond to and resolve help desk/received customer inquiries via written, telephonic and/or various platform-type communication systems in a timely and accurate manner in compliance with organizational KPI/SLAs; provide guidance regarding complex and/or escalated inquiries. (40%)
- Provide processing instruction to claims adjudicator(s) and review payment levels to arrive at final payment determination. (25%)
- Work with provider network to solve claim inquiries and escalates issues to next level of supervision as appropriate. (15%)
- Assist with internal communication-related tasks. (10%)
- Perform research on new markets to inform internal system database. (5%)
- Attend required training classes. (5%)
- Other duties as assigned or requested.
- 5 years of experience in Customer Service
- 5 years of experience in Claims Support and Processing
- 5 years of experience in Revenue Cycle
- Critical Thinking
- Customer Service
- Problem Solving
- Business Intelligence
- Strong Written and Verbal Communication Skills
- Microsoft Office Products
- High School/GED
LICENSES or CERTIFICATIONS
Language (Other than English):
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others
Travel from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:$17.20
Pay Range Maximum:$27.82
Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
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
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