CUSTOMER SERVICE REP I

Location: Wilkes Barre Public Square

Work Schedule: Days

Work Type: FULL TIME

JOB SUMMARY :

Assists Customer Service Team Leader in resolving customer concerns, providing appropriate education/instruction and maintaining customer satisfaction by providing the highest level of customer service in only one of the Primary Functions (enrollment, claims or phones).

Proficient in one or more of the three GHP lines of business including the following product designs:

HMO which includes: HMO, HMO Point of Service, HMO Extra, HMO Point of Service Extra, Solutions HMO, Solutions Point of Service, Solutions Extra, Solutions Point of Service Extra, GHP Direct, GHP Solutions Direct, GHP Direct Point of Service, GHP Solutions Direct with Point of Service, Choice PPO with Referral, Marketplace Solutions, Marketplace Solutions Extra, Marketplace Solutions QHDHP, Marketplace Value, Marketplace HMO, Marketplace HMO POS, Marketplace HMO HDHP and Marketplace HMO Extra.

TPA which includes: High Deductible Health Plan, Choice PPO no referral, Direct Access, Indemnity, Marketplace Direct, Marketplace Direct QHDHP and all self-funded third party administrators including GHS.

Gold which includes: . Classic Advantage, Classic Complete Rx, Secure Rx, Preferred Advantage,Preferred Complete, Preferred Essential, Preferred Select, PA-MSA Reserve, NJ Classic Rx, NJ Preferred Rx, NJ –MSA Reserve

Actively participates in cross training, improving processes within the Customer Service team. Responsible for attaining and maintaining “key performance measures” established for the Customer Service Team in the primary functions of claims, enrollment and phones.

Works under the direction of the Customer Service Team Leader.

Cross training is based on experience and departmental need.

MAJOR DUTIES AND RESPONSIBILITIES:

A. Enrollment:

*1. Processes, codes, interprets and data enters all enrollment activity in Amisys system by interpreting multiple electronic reporting systems as well as paper applications.

*2. Resolves and reconciles enrollment reports and all related eligibility issues by following GHP Departmental policy and procedure as well as any state legislated coverage and eligibility guidelines as set forth by the DOI.

*3. Initiates communication and literature to the newly enrolled Health Plan member, dependents and employer groups; acting as a liaison for client/groups and Marketing and Sales staff.

*4. Interprets and appropriately applies rules and regulations in existing GSA and contractual agreements in place with employer groups and vendors in order to support Health Plan and departmental guidelines.

*5. Regularly performs membership data extract reports and supplies them to employer groups as an audit tool for accuracy and compliance with performance risk guarantee commitments.

*6. Responsible for decision making, updating, approving and interpreting membership data and workflow produced by GHP online software capabilities in AboveHealth employer group modules.

7. Performs research on a daily basis to comply with all of the mandated tenets of eligibility and to help inform and update members and employer groups on new or historical information.

8. Performs electronic Mass Transfer functions to move membership to and from specific group divisions as called for.

9. Directly responsible for determining the eligibility of most members as well as processing terminations/disenrollments while adhering to and complying with HIPPA mandated guidelines when applicable.

10. Prepares, generates and appropriately disseminates letter communications to subscribers and members with regard to enrollment activity by following internal and external guidelines for member and subscriber information (i.e., termination notices, newborn letters, etc.).

11. Calculates the number of uncovered months for imposing the Late Enrollment Penalty for Gold Part D.

12. Verifies Gold eligibility by utilizing the Marx (CMS-Centers for Medicare and Medicaid Services) system.

13. Answers inbound calls from the Broker line regarding enrollment/plan inquiries.

14. Transmits enrollment data to CMS using the Electronic file transfer system knows as EFTS.

15. When processing gold elections, populates broker field with broker and sales representatives numbers in the amisys contract screen.

16. Verifies eligibility for Secure and PACE members by validating monthly files received from the state (DPW).

17. Prints labels and mail signature cards to Mellon Bank for the Gold Reserve Plan.

18. Works daily/weekly edit reports for the Gold Reserve Plan.

19. Must be able to maintain member/provider confidence by helping to protect the confidentiality of information coming into and being disseminated out of the department according to HIPAA guidelines.

20. Meets and maintains departmental standards.

21. Provides training within the team as needed.

22. Assists Team Leader with special projects related to enrollment.

B. Claims:

*1. Reviews claims received for completeness and eligibility and enters data into Amisys system.

*2. Determines if services received are covered benefits as applicable by line of business and product design. Follows the appropriate claims processing guidelines according to provider contracts.

*3. Communicates and coordinates with the appropriate internal GHP department to resolve claim issues.

*4. Reviews suspended claims for resolution by applying current policies, procedures and benefits applicable to specific GHP products.

5. Responsible for reviewing and maintaining a working understanding of all claims processing and procedures for current criteria for claims resolution.

6. Assists Team Leader with special projects related to claims adjudication and claims adjustments.

7. Provides team building resources to assist in directing peers to proper claims resolution policies and procedures in order to assist members and providers.

8. Provides daily support and advice to member/provider services staff regarding claims issues.

9. Takes responsibility for claim issues generated by incoming calls from providers and members.

10. Develops and maintains awareness and working knowledge of Amisys Advanced, IDM Tower, Burgess Reimbursement Software, GHP Encyclopedia systems, GHPs external website and Abovehealth.

11. Maintains an acceptable understanding of claims adjudication, referral application, coverage determination and explanation code assignments.

12. Performs duties to support the Health Plan to provide member health care, member and provider satisfaction.

13. Meets and maintains departmental standards.

14. Maintains the security and confidentiality of data.

15. Participates in workgroup meetings to achieve improvements within the department.

16. Troubleshoots possible system errors and coordinates with the appropriate internal departments for resolution.

17. Maintains knowledge of all Health Plan products in order to provide the highest level of customer service and support to members, providers and employers.

18. Researches claim issues from participating providers and identifies specific criteria for reconsideration for payment.

19. Must be able to maintain member/provider confidence by helping to protect the confidentiality of information coming into and being disseminated out of the department according to HIPAA guidelines.

20. Provides direct feedback for all web service features.

C. Phones:

1. Act as a liaison between the member/provider and Geisinger Health Plan in resolving claims, benefit and eligibility concerns.

2. With direction from the Customer Service Team Leader this position demands thorough knowledge of products and processes to respond to questions from customers and prospective customers. At all times, demonstrating the highest level of diplomacy and professionalism.

3. Serve as primary contact for members and providers. Maintains strong relationships with members and providers through telephone contact, written correspondence, and on site visits.

4. Investigates all concerns/issues to assure accurate information is provided in a timely manner. Responsible for resolution for all member/provider concerns and inquiries.

5. Maintains proficiency in all benefit changes and the ability to effectively communicate benefit inquiries to members/providers.

6. Must be able to maintain member/provider confidence by helping to protect the confidentiality of information coming into and being disseminated out of the department according to HIPAA guidelines.

*7. The Customer Service Representative will be held responsible for the establishment and maintenance of member/provider relations.

*8. Communicates and coordinates with the appropriate internal GHP department to resolve member/provider concerns.

*9. Documents and codes accurately all inquiries/concerns according to departmental policy in the Amisys System.

*10. Responsible to communicate to members and/or providers the complaint/appeal and grievance process. Documents complaint/appeal and grievances and forwards to the appropriate Customer Service Complaint Representative for processing.

11. Provides team building resources to assist in directing peers to appropriate policies and procedures in order to assist members and providers

12. The ability to make outbound calls to providers and members to resolve complex benefit, eligibility and claims issues.

13. Determines appropriateness of benefit under corresponding lines of business as defined under the Geisinger Health Plan.

14. Provides direct feedback for all web service features.

15. Meets and maintains departmental standards.

16. Performs other duties as required or assigned.

*Denotes essential job functions.

COMPETENCIES AND SKILLS:

Demonstrates excellent communication, problem solving, and customer-service skills within a team atmosphere.

Demonstrates excellent organization and time management skills and ability to work independently.

Demonstrates ability to work with and manage multiple data sets. Demonstrates good verbal and written skills and ability to work with all levels of Health Plan personnel.

Demonstrates competence in written, oral and electronic communication skills (interpersonal/communication and technological effectiveness competencies).

Demonstrates the ability to be flexible to change.

Demonstrates the ability to be a team player.

Strong keyboarding skills.

Demonstrates competence in maintaining department standards in a fast paced office environment.

Demonstrates ability to be detail oriented.

Demonstrates ability to multitask and function under pressure to ensure Health Plans goals are met.

Demonstrates customer service skills.

Demonstrates strong problem solving skills.

Demonstrates ability to participate in problem solving situations.

Demonstrates strong organizational and analytical skills.

Demonstrates the ability to maintain confidentiality.

EDUCATION AND/OR EXPERIENCE:

High School diploma and minimum one year customer service, hospital or insurance experience, including patient or public contact, required.

If primary function is in claims, basic knowledge of the CPT-4, HCPCS and ICD-9-CM coding manuals preferred.

WORKING CONDITIONS/PHYSICAL DEMANDS:

Work is typically performed in an office environment.

The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

About Geisinger

Geisinger Health System is an integrated health services organization widely recognized for its innovative use of the electronic health record and the development of innovative care delivery models such as ProvenHealth Navigator® and ProvenCare®. As one of the nation’s largest health service organizations, Geisinger serves more than 3 million residents throughout 45 counties in central, south-central and northeast Pennsylvania, and also in southern New Jersey with the addition of AtlantiCare, a National Malcolm Baldridge Award recipient. The physician-led system is comprised of approximately 30,000 employees, including nearly 1,600 employed physicians, 12 hospital campuses, two research centers and a 510,000-member health plan, all of which leverage an estimated $8.9 billion positive impact on the Pennsylvania economy. Geisinger has repeatedly garnered national accolades for integration, quality and service. In addition to fulfilling its patient care mission, Geisinger has a long-standing commitment to medical education, research and community service. For more information, visit www.geisinger.org, or follow the latest Geisinger news and more on Twitter and Facebook.

** Does not qualify for J-1 waiver. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.