Telephone Representative II (Provider Relations)

1199seiu; New York (NY); On-site; USD 42,000 - 54,000; Full time

Job summary

1199SEIU seeks a detail-oriented health benefits specialist to assist members, providers, and facilities by handling eligibility, claims inquiries, and documentation requests. You will verify coverage, verify schedules for procedures, and guide providers on program changes.

Strong communication, multi-tasking, and familiarity with claims systems such as QNXT and Vitech are preferred. The role requires professional telephone service and accurate record-keeping in a fast-paced environment.

Qualifications

• High School Diploma or GED; Some College or Degree preferred.
• Minimum two years high-volume customer service in a call center or two years health claims processing experience.
• Excellent Keyboarding Skills.
• Experience using health claims systems (QNXT, Vitech) and Fund eligibility requirements preferred; Provider relations a plus.
• Excellent written and verbal communication skills with strong interpersonal abilities.
• Ability to initiate correspondence and maintain a polite, helpful demeanor.
• Ability to multi-task and work under pressure; call center hours 8:00 am–6:00 pm.

Responsibilities

• Communicate with doctors, hospitals, and other professionals via telephone regarding members, eligibility, claims, and plan services.
• Verify and determine eligibility for members, spouses, dependents, including reinstatement of terminated coverage.
• Research and request documentation for provider enrollment, credentialing and provider file updates.
• Research schedule of allowances for procedure codes and prior authorization requirements; check reconciliation of claim payments.
• Respond to telephone inquiries regarding member benefits and claims.
• Examine claim histories for status, accuracy and timeliness.
• Create call tracking records in QNXT; mail printed materials upon request.
• Review call tracking items for closure or reallocation as needed.
• Assign inquiries to appropriate call tracking folders for resolution.
• Generate call tracking inquiries for problems related to above.
• Advise providers of new programs, plan improvements and plan changes.
• Verify provider inquiries using Knowledge Tools.

Skills

Keyboarding

Communication skills

Multi-tasking

Customer service

Interpersonal skills

Education

High School Diploma or GED

Some College or Degree

Tools

QNXT

Vitech

DocFind

iObserver

IRIS System

Job description

Responsibilities

• Communicate with doctors, hospitals, and other professionals via telephone regarding 1199SEIU members, dependent eligibility for health benefits, claims, and other plan services


• Verify and determine eligibility for members, spouses, dependents, including the reinstatement of terminated coverage


• Research and request documentation for provider enrollment, credentialing and provider file updates


• Research and provide schedule of allowance for procedure codes and prior authorization requirements, research check reconciliation of claim payments


• Accurately and professionally respond to telephone inquiries regarding member benefits and claims


• Examine dental, vision, hospital, and medical claim histories for claim status, accuracy and timeliness


• Create call tracking records in call tracking system (QNXT) to the appropriate call tracking folders for resolution; mail printed materials upon request


• Review call tracking items returned to individual folder for closure or assignment to correct call tracking folder as required


• Assign claim inquiries, enrollment, and eligibility issues to appropriate call tracking folders for resolution


• Generate call tracking inquiries for problems related to all of the above for correction


• Advise providers of new programs, plan improvements and plan changes


• Verify provider inquiry using Knowledge Tool (BeneFAQs, QNXT, DocFind, iObserver)


• Retrieve and review scanned claim images using IRIS System


• 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 customer service experience in a call center environment; or two (2) years health claims processing experience required


• Excellent Keyboarding Skills Required.


• Experience using web-based applications, basic knowledge of health claims processing systems (QNXT, Vitech) and Fund eligibility requirements preferred (National Benefit Fund, Greater New York Fund, Home Care Fund); experience with Provider Relationsa plus


• Excellent written and verbal communication skills with great interpersonal skills


• Ability to initiate own correspondence and maintain a pleasant attitude to ensure excellent service to members and providers


• Ability to multi-task and work under pressure due to volume and urgent nature of calls


• Call Center hours of operation are from 8:00 am - 6:00 pm;shifts are subject to change and/or availability