Quality Control Reviewer III

1199SEIU Benefit and Pension Funds; New York (NY); On-site; USD 60,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated Call Center Representative to join their dynamic team. This role involves conducting audits, mentoring staff, and resolving complex health claims inquiries while ensuring excellent customer service. The ideal candidate will have a strong background in call center operations, particularly within health plans or benefits environments. You will work closely with various departments to troubleshoot issues and enhance provider relations. If you thrive in a fast-paced environment and possess exceptional communication skills, this opportunity is perfect for you to make a meaningful impact in the healthcare sector.

Qualifications

• 2+ years of high volume call center experience in a health plan or benefits environment.
• Comprehensive knowledge of health benefits and eligibility rules.

Responsibilities

• Conduct audits and communicate with various professionals regarding health claims.
• Assist in mentoring staff and resolving complex provider inquiries.

Skills

Communication Skills

Problem Solving

Analytical Skills

Customer Service

Multi-tasking

Education

High School Diploma or GED

Some College or Degree

Tools

Vitech

QNXT

Call Tracking Systems

iObserver

Job description

Responsibilities:

1. Conduct audits of Provider Relations call center inquiries via various systems (i.e. Vitech, QNXT, and Call Tracking)
2. Communicate with providers, collection agencies, hospitals, doctors, dentists, lawyers, employers, and other professionals regarding health claims and other benefit inquiries; provide backup coverage to Telephone Representatives as needed
3. Assist Supervisor in reviewing work of call center staff and redistribute errors; provide departmental training and side-by-side mentoring of staff
4. Assist Telephone Representatives with difficult calls and resolve complex problems
5. Investigate issues, provider advances and assist providers with claim payments or adjustments
6. Work closely with various departments, insurance carriers and other agencies to resolve issues (i.e. Provider Relations, Claims, Finance, Eligibility and Coordination of Benefits)
7. Review eligibility and claims systems for errors and call track and/or escalate inquiries for corrections or adjustments
8. Review and monitor department call tracking folder, process call tracking inquiries, identify trends and troubleshoot problems
9. Access web-based or report applications relevant to provider inquiries (i.e. ABF, iObserver, intranet, on-demand reports, or external provider websites)
10. Review and search information using knowledge tool (i.e. BeneFAQs)
11. Must meet departmental performance standards
12. Perform additional duties and projects as assigned by management

Qualifications:

1. High School Diploma or GED required, some College or Degree preferred;
2. Minimum two (2) years high volume call center experience as a Telephone Representative in a health plan or benefits environment required
3. Comprehensive knowledge of eligibility, rules for extended or limited continuation of benefits (coordination of benefits, retiree extensions, enrollment)
4. Comprehensive knowledge of health benefits such as: hospital, surgical, x-ray, laboratory, major medical, etc.
5. Knowledge of 1199SEIU Fund benefits preferred (National Benefit Fund, Greater New York and Home Care Fund)
6. Experience navigating web based applications and Call Tracking Systems (Vitech, QNXT, iObserver and IRIS)
7. Excellent communication skills (written and verbal) and interpersonal skills; ability to maintain a pleasant attitude with providers to ensure customer satisfaction
8. Able to work well under pressure, multi-task, establish priorities, meet deadlines, and follow up
9. Strong ability to lead, mentor and motivate others, maintain professional manner and presentation
10. Good problem solver and excellent analytical skills
11. Call Center hours of operation are from 8:00 am until 6:00 pm; shifts are subject to change and/or availability
12. Must meet attendance and punctuality standards