Position Purpose: This position responds to all incoming calls, and member walk-ins. Provides information as requested relating to enrollment, review of status, and claims. The CSR researches payment of claims, coordination of benefit problems, enrollment issues, pharmacy issues, COBRA questions and, as needed, employer group or provider problems/issues. In conjunction with Case Management, coordinates and investigates off-plan referrals, and works to resolve all third party vendor issues.

Primary Responsibilities:

To perform this job successfully, the individual must be able to perform each essential duty in accordance with the Customer Service Departmental standards (the requirements listed below are representative of the knowledge, skill and/or ability needed). Reliable, consistent and predictable performance of the following job duties is required:

• Responds effectively, efficiently and professionally to all incoming calls, emails, web portal inquiries, and walk-ins.
• Provides information to multiple client bases concerning benefits and coverage, as well as claims status.
• Assists member with pharmacy issues by contracting PBM and pharmacy as a liaison.
• Provides information and support for claims adjustment processes.
• Verifies member eligibility and benefits to all appropriate callers.
• Supports member ID card production, including mailing, corrections, returned mail, etc.
• Tracks and trends provider issues for coordination with Provider Network Services Department.
• Maintains current product, medical policy, contract information, and other reference materials.
• Investigates and may take new member COB information over the phone.
• Quotes and tracks transplant/specialty cases, working with the Claims Transplant Analyst.
• May perform duties such as testing system, auditing explanation of benefits, assisting with mailings for other areas, training back-ups, learning newly developed products, and attending CSR meetings.
• Utilizes extensive department reference tools effectively, such as Encoder Pro, scanning/records retention programs, policies, procedures and guidelines to accurately answer all questions.
• Maintains departmental standards relative to accuracy, assuring compliance with federal and state laws.
• Researches and utilizes precertification information.
• Assists Customer Service Supervisor with the development and maintenance of departmental policies, procedures and workflows.
• Performs additional duties as requested:

• Prepares the appeals to go to Zelis by scanning documents, entering information in the Claim-Pro system and filing through the Zelis portal.
• Enters precertification information in the Claim-Pro system.
• Reprices claims for specific networks.
• Composes overpay letters and follow up on a timely basis.
• Creates the monthly working schedule making sure adequate coverage for all time periods.
• Maintains current dental schedules to fax to providers.
• Is the liaison with outside law office that reviews all Subrogation claims by gathering medical documentation, police reports, and claims information. Also provides claims paid reports for law office and makes the client aware of all situations.
• Creates letters for clients such as: requesting TPL information, HIPAA authorizations, medical records requests, and claim paid by patient reports when needed

17. Monitors daily open call report for follow-up and resolution.

18. Monitors services levels in phone ques.

19. Participates in company-wide and departmental quality management activities as needed.

20. Participates in training on federal and state regulations applicable to position, and adheres to same.

21. Performs any relevant and related duties as required

Experience: A High School Degree or equivalent. Three to five (3-5) years of progressively responsible work experience in a customer service area, preferably within the insurance or managed healthcare industry. Knowledge of medical terminology is preferred.