Quality Control Reviewer III

1199SEIU Benefit and Pension Funds; New York (NY); On-site; USD 45,000 - 60,000; Full time

Job summary

1199SEIU Benefit and Pension Funds is seeking a detail-oriented professional to conduct audits of Provider Relations call center inquiries across systems such as Vitech, QNXT, and Call Tracking. You will communicate with providers, collection agencies, hospitals, doctors, dentists, and others to resolve health claim inquiries and provide backup coverage to Telephone Representatives.

The role requires at least two years of high-volume call center experience in a health plan environment, strong

Qualifications

• High School Diploma or GED required; some college or degree preferred.
• Minimum two (2) years high-volume call center experience in a health plan or benefits environment.

Responsibilities

• Conduct audits of Provider Relations call center inquiries via systems (Vitech, QNXT, Call Tracking).
• Communicate with providers, collection agencies, hospitals, doctors, dentists, lawyers, employers, and other professionals regarding health claims and benefits inquiries; provide backup coverage to Telephone Representatives.
• Assist Supervisor in reviewing work of call center staff and redistribute errors; provide 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 with various departments, insurance carriers and other agencies to resolve issues (Provider Relations, Claims, Finance, Eligibility, COB).
• Review eligibility and claims systems for errors and escalate inquiries for corrections or adjustments.
• Review and monitor department call tracking folder, process inquiries, identify trends and troubleshoot problems.
• Access web-based or report applications relevant to provider inquiries (ABF, iObserver, intranet, on-demand reports, external provider websites).
• Review and search information using knowledge tool (BeneFAQs).
• Must meet departmental performance standards.
• Perform additional duties and projects as assigned by management.

Skills

Excellent communication skills

Interpersonal skills

Lead, mentor and motivate others

Problem solving

Analytical skills

Customer service

Multitasking

Work under pressure

Follow-up

Education

High School Diploma or GED

Tools

Vitech

QNXT

iObserver

IRIS

ABF

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 escalate 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