Quality Control Reviewer III

1199SEIU Benefit and Pension Funds; New York (NY); On-site; USD 35,000 - 55,000; Full time

Job summary

An established industry player is seeking a dedicated Telephone Representative to support members with their benefits inquiries. This role involves maintaining HIPAA compliance, verifying benefits, and providing exceptional service in a high-volume call center environment. The ideal candidate will have strong interpersonal and communication skills, along with the ability to navigate various web-based applications efficiently. Join a dynamic team committed to delivering quality service and making a difference in the lives of members by ensuring they receive the benefits they deserve.

Qualifications

• 2+ years of experience in a high volume call center environment required.
• Comprehensive knowledge of eligibility guidelines and benefit entitlements is essential.

Responsibilities

• Maintain HIPAA compliance while assisting members with benefits inquiries.
• Verify and establish benefits for members using various systems.

Skills

Interpersonal Skills

Communication Skills

Problem-Solving

Web-Based Application Navigation

Leadership Ability

Education

High School Diploma or GED

Some College or Degree

Tools

V3

QNXT

Express Scripts

Word

Excel

Document Management System (DMS)

Job description

Responsibilities

• Maintain HIPAA compliance while communicating with members and advocates in person or by telephone regarding all 1199SEIU benefits and programs
• Verify, establish and re-establish benefits for members and eligible dependents enrolled in all Funds using various systems (V3, QNXT, Express Script, etc.), receive Premium Payments for applicable Funds (GNY), receive COBRA payments and provide invoices for COBRA inquiries
• Update V3 Eligibility with changes to the member demographics (COA’s) upon request
• Document completion of window service per visitor in Queue Management System (Q-Matic)
• Initiate call tracking inquiries claims processing system (QNXT) with eligibility or claim errors for corrections, updates, or payment adjustments
• Audit QNXT Call Tracking Inquiries received from members, or member advocates for accuracy of content and delivery to the appropriate department as needed; identify trends and troubleshoot problems
• Verify coordination of benefits with other carriers and agencies
• Work closely with various departments (i.e., Provider Relations, Finance, and Claims) to resolve issues
• Assist in departmental training or side-by-side mentoring of staff
• Retrieve images and documents through document management system (DMS) to assist members or representatives
• Maintain files of documents accepted at windows; collect data for reports, record trends and make outbound calls
• Access web-based applications relevant to member inquiries (i.e., iObserver, Express scripts and Intranet)
• Enter notes or comments as appropriate in (QNXT and V3)
• Perform additional duties and projects as assigned by management

Qualifications

• High School Diploma or GED required, some College or Degree preferred
• Minimum two (2) years high volume call center experience as a Telephone Representative in a health insurance or benefits environment required
• Basic knowledge of Word and Excel preferred
• Comprehensive knowledge of eligibility guidelines and benefit entitlements (1199SEIU National Benefit Fund, 1199SEIU Greater New York and New Jersey, 1199SEIU Home Care Fund, 1199SEIU LPN) and plan rules required
• Knowledge of Disability Benefits, Family Medical Leave Act (FMLA) and Worker’s Compensation for extended coverage
• Knowledge of Medical, Hospital, Dental, Eligibility and other web-based systems (i.e. V3, QNXT, BeneFAQs, Express scripts and iObserver)
• Excellent interpersonal and communications skills; pleasant demeanor to diffuse irate members
• Ability to initiate own correspondence; demonstrate proficient navigation skills of web-based applications
• Ability to work under pressure independently and as a team
• Exhibit leadership ability, including professional appearance at all times
• Member Services hours are from 8:00 am until 6:00 pm; shifts are subject to change and/or availability