Job Summary
Processes returned checks related to claims processed by the company and its affiliates by reviewing and researching related claim information and contacting and providing customers with complete, accurate and timely responses to check control inquiries.
This is a bargaining unit position. The collective bargaining agreement for this position requires that candidates and employees reside in the following counties in the State of New York: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, or Wyoming.
Duties Note: The following is not intended to be an exhaustive list of all duties required of this position.
ADA
E1. Processes checks returned to the company related to claims: •Investigates and researches returned company and/or personal checks from customers; takes appropriate action in accordance with corporate procedures to determine check disposition. •Maintains accurate and organized records reflecting department activity and claim traffic. •Enters criteria data into Corporate software systems. •Checks and sorts Provider remittance statements.
E2. Reviews claims related to returned checks, for processing and data entry: •Performs on-line transactions and /or adjustments utilizing the corporate claims administration system and ITS Standard Formats, FEP Direct and procedures if applicable. •Prepares written documentation that substantiates and supports the filing of system trouble tickets and change requests as a result of claims reviews/inquiries.
E3. Completes correspondence and/or contacts customers as necessary for additional information: •Answers both written and verbal inquires from internal and external customers. •Completes Letter Reference Guide (LRG) templates to send correspondence to if required for additional information.
E4. Processes retraction requests relating to claims: •Accesses third party website to review identified invoices for retraction requests. •Creates intake and routes with related information to other departments.
E5. Identifies potential fraudulent cases and forwards to Special Investigation Department or Other Party Liability/Savings Recovery for further review.
E6. Reviews negative balance report: •Reviews negative balance report; confirms accurate and complete Provider information. •Requests voucher for overpayment; completes corresponding template letter to send to Provider.
N7. Performs other related clerical duties: •Files, faxes, copies documents.
E8. Performs all job duties efficiently, accurately and at an acceptable rate of performance.
E9. Maintains confidentiality and adheres to HIPAA regulations.
E10. Delivers customer service in a professional, polite and efficient manner.
N11. Performs other duties of a similar nature that are necessary and not inconsistent with this position or pay grade.
Education/Experience/Skills Requirements
Required Education:
HS/GED:
Required Experience:
Two (2) years previous work experience in a healthcare related field as demonstrated by proficiency in one or more of the following: claims coding and keying, claims processing, customer or provider service. Preference will be given to candidates with previous claim processing experience or t he equivalent.
Preferred Education:
Associates Degree: Accounting, Business Admin., Finance
Preferred Experience:
AND 1–2 years previous experience in Accounting, claims processing or health insurance related field is preferred.
Required Knowledge/Skills:
1. Must meet qualifications to perform the job including satisfactory completion of all training and testing
2. Typing Skills: 30 WPM
3. Job Content test
4. Correspondence test for business letter correspondence
5. Basic Computer Literacy test
6. Ability to multitask in fast paced environment
7. Well organized with ability to adapt to changing business environment; exhibits attention to details and time management skills
8. Proficiency in English language skills, including spelling, punctuation and grammar, in both written and verbal communication to ensure communications are issued in a professional manner
9. Ability to effectively communicate with internal and external contacts in a professional manner
10. Working knowledge of personal computer and application software such as Microsoft Office
11. Computer Software typically used: Content Manager, Facets, OnDemand, People Soft/UCDS
12. Ability to utilize basic office equipment including PC, scanner, telephone, copier, printer, fax, calculator
Required Licenses/Certifications:
Problem Solving
Identifies issues and problems, identifies key facts and seeks information to resolve returned checks.
Managerial/Supervisory Responsibilities
Does this Position have Supervisory Responsibility? No
Number of Emps Supervised:
Titles of Employees Supervised:
Financial/Budgetary Responsibilities:
Other Job Specifications:
External Contacts: Customers, members, subscribers, providers
Working Conditions/Physical Demands:
Position requires:
* Must be able to work in an office environment
Position involves:
* Physical Effort: Minimum; typical of most office work. Mostly sedentary work.
* Weight: lift/carry/push/pull under 10 lbs.
* Prolonged Sitting
* Repetitive Motion
* Reaching
* Bending
* Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
* Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
* Vision Req: Close vision (clear vision at 20 inches or less)
Pay Rate:
The starting hourly rate for this position listed above is for new employees. This rate has been established by the Local 153, Office and Professional Employee International Union (OPEIU) collective bargaining agreement (CBA) and is non-negotiable. If the successful candidate is currently a bargaining unit member of the OPEIU, hourly rate is commensurate with their anniversary year and pay grade as per the CBA.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )
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