Telephone Representative II
1199SEIU Family of Funds - New York, NY

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Responsibilities
  • Communicate with members, providers, vendors, and other professionals via telephone or written correspondence regarding claims, benefit request, and inquiries
  • Research eligibility, claims history, and patient notes prior to benefit determinations for Home Care Services, DME, Medco, and interact with staff as required
  • Generate inquiries for unresolved requests related for prospective/concurrent and retrospective utilization review and prescription (Rx) requests received
  • Direct members to use our participating providers and preferred vendors to ensure that member incurs minimal or no out-of-pocket expenses for covered services after preferred medication alternatives
  • Inform and educate members, providers, and vendors on standard protocols, new programs, plan improvements, or modifications as it pertains to Prior-Authorization (PA)
  • Document information and/or determinations in call tracking system (QNXT) memo notes as needed
  • Create authorization for Medco Home Care Services, DME, Medical supplies, etc.
  • Distinguish the benefit plans per Fund; identify the appropriate enrollment as eligibility rules and required documentation
  • Create call-tracking records (QNXT) to assign and distribute inquiries to the appropriate departmental folders for resolution
  • Access web-based application relevant to member inquiries (Observer, Medco, QNXT, V3, Portal, etc.)
  • Verify and establish eligibility for members, spouses, dependents in order to enter authorization
  • Accurately and professionally respond to telephone inquiries regarding member benefits and claims
  • Mail printed materials upon request
  • Perform additional duties and projects as assigned by management
Qualifications
  • High School Diploma or GED required; some College or Degree preferred; plus
  • Minimum two (2) years high volume customer service experience in a call center environment; or two (2) years health claims processing experience required
  • Knowledge of health claims processing systems (QNXT, V3) and Fund eligibility requirements preferred (National Benefit Fund, Greater New York Fund, Home Care Fund )
  • Excellent written and verbal communication skills with great interpersonal skills
  • Ability to multi-task and work under pressure due to volume and urgent nature of calls
  • Call Center hours of operation are from 9:00 am – 5:00 pm; shifts are subject to change upon departmental needs
  • Must meet performance standards including attendance and punctuality

1199SEIU Family of Funds - 16 months ago - save job - block
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