This role is customer facing and is considered a key customer service representative for the Health Fund. The Senior Participant Service Specialist/Analyst will process health insurance claims and answers calls from the customer (participant, providers, physicians, hospitals etc.) Adhere to eligibility, claims and call policies and procedures while making sound claim/call decisions. Foster strong relationships through the resolution of customer incoming call requests. Serve our customers by determining requirements, answering inquiries, resolving problems, fulfilling requests and maintaining key performance measures. Build strong working relationships with others within the company by demonstrating effective people skills and interpersonal savviness.

Essential Job Functions:

- Meet all key performance indicators established for this position in the areas of: efficiency, accuracy, quality, productivity, system adherence, customer satisfaction and attendance
- Elevate and enhance the Health Funds reputation by providing World Class Customer Service
- Answer incoming phone calls from customers and identify the type of assistance the customer needs (e.g. benefit and eligibility, billing and payment inquiries, authorizations for treatment and explanation of benefits (EOBs))
- Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in real-time
- Communicate and collaborate with customer to resolve issues, using clear, simple language to ensure understanding
- Fulfill requests by clarifying desired information; forward requests and follow through on all customer commitments
- Resolve problems by interpreting and clarifying issues; researching and exploring answers and alternative solutions; implementing solutions; addressing unresolved problems
- Review and research incoming healthcare claims by navigating multiple computer systems and platforms and verify the data/information necessary for processing (e.g. pricing, prior authorizations, and applicable benefits)
- Go the extra mile to engage customers
- Ensure that the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, grievance procedures, federal mandates, CMS/Medicare guidelines, and benefit plan documents/certificates)
- Train and coach new staff

Analysis Function:

- Analyzes existing business procedure documentation to identify content gaps or inconsistencies and prepares new or updated documentation, flowcharts, processes and procedures
- Assesses business processes and identifies opportunities for improvement
- Evaluates and prepares for expected changes in software applications or regulatory mandates across business processes and procedures
- Conducts research and analysis of historical, current and future benefit trends, service improvements and impacts to fund
- Identifies internal control weaknesses and makes recommendations for improvements
- Maintains and develops a detailed library of policies and procedures including new or updated documentation, flowcharts, policies and procedures
- Works with Team to conduct analysis focused on improving business process flow and customer issue resolution

We are a company committed to creating inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity employer that believes everyone matters. Qualified candidates will receive consideration for employment opportunities without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, disability, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to Human Resources Request Form. The EEOC "Know Your Rights" Poster is available here.

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