Quality Control Reviewer III

1199seiubenefits; New York (NY); Hybrid; USD 42,000 - 62,000; Full time

Job summary

1199SEIU Benefits is seeking a Provider Relations Call Center Associate to audit inquiries across Vitech, QNXT, and Call Tracking systems, ensuring accurate resolution of health claim and benefit questions. You will interact with providers, hospitals, and other professionals, support supervisors, mentor staff, and help improve departmental processes while meeting performance standards.

Required: high school diploma, 2+ years in a high-volume health plan call center, strong communication and

Qualifications

• High School Diploma or GED required; some college or degree preferred.
• Minimum two years of high-volume call center experience in a health plan or benefits environment.
• Knowledge of eligibility rules for extended or COB benefits.
• Knowledge of health benefits such as hospital, surgical, and lab services.
• Familiarity with 1199SEIU Fund benefits (national and NY files) preferred.
• Experience navigating web-based applications and call tracking systems.
• Excellent communication and interpersonal skills; ability to maintain a pleasant attitude with providers.
• Able to work under pressure, multi-task, set priorities, meet deadlines, and follow up.
• Strong leadership, mentoring, and motivational skills.
• Call Center hours are 8:00 am–6:00 pm; shifts subject to change.

Responsibilities

• Audit audits of Provider Relations call center inquiries using systems like Vitech, QNXT, and Call Tracking.
• Communicate with providers, collection agencies, hospitals, doctors, dentists, lawyers, and employers regarding health claims and benefits inquiries; provide backup coverage as needed.
• Assist Supervisor in reviewing work, redistribute errors, and provide departmental training and mentoring.
• Assist Telephone Representatives with difficult calls and resolve complex problems.
• Investigate issues, provider advances, and assist with claim payments or adjustments.
• Collaborate with Provider Relations, Claims, Finance, Eligibility and COB teams to resolve issues.
• Review eligibility and claims systems for errors and route inquiries for corrections.
• Monitor the department call tracking folder and process inquiries; identify trends and troubleshoot.
• Access web-based or report applications relevant to provider inquiries (ABF, iObserver, intranet, on-demand reports, external provider sites).
• Review and search information using knowledge tools (BeneFAQs).
• Must meet departmental performance standards.
• Perform additional duties and projects as assigned by management.

Skills

Excellent communication

Mentoring

Multi-tasking

Interpersonal skills

Attention to detail

Education

High School Diploma or GED

Some College or Degree preferred

Tools

Vitech

QNXT

iObserver

IRIS

Job description

Responsibilities

• Conduct audits of Provider Relations call center inquiries via various systems (i.e. Vitech, QNXT, and Call Tracking)
• 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
• Assist Supervisor in reviewing work of call center staff and redistribute errors; provides departmental training and side‑by‑side mentoring of staff
• Assist Telephone Representatives with difficult calls and resolve complex problems
• Investigate issues, provider advances and assist providers with claim payments or adjustments
• Work closely with various departments, insurance carriers and other agencies to resolve issues (i.e. Provider Relations, Claims, Finance, Eligibility and Coordination of Benefits)
• Review eligibility and claims systems for errors and call track and/or elevate inquiries for corrections or adjustments
• Review and monitor department call tracking folder, process call tracking inquiries, identify trends and troubleshoot problems
• Access web‑based or report applications relevant to provider inquiries (i.e. ABF, iObserver, intranet, on‑demand reports, or external provider websites)
• Review and search information using knowledge tool (i.e. BeneFAQs)
• Must meet departmental performance standards
• 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 plan or benefits environment required
• Comprehensive knowledge of eligibility, rules for extended or limited continuation of benefits (coordination of benefits, retiree extensions, enrollment)
• Comprehensive knowledge of health benefits such as: hospital, surgical, x‑ray, laboratory, major medical, etc.
• Knowledge of 1199SEIU Fund benefits preferred (National Benefit Fund, Greater New York and Home Care Fund)
• Experience navigating web based applications and Call Tracking Systems (Vitech, QNXT, iObserver and IRIS)
• Excellent communication skills (written and verbal) and interpersonal skills; ability to maintain a pleasant attitude with providers to ensure customer satisfaction
• Able to work well under pressure, multi‑task, establish priorities, meet deadlines, and follow up
• Strong ability to lead, mentor and motivate others, maintain professional manner and presentation
• Good problem solver and excellent analytical skills
• Call Center hours of operation are from 8:00 am until 6:00 pm; shifts are subject to change and/or availability
• Must meet attendance and punctuality standards