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Job Details

Senior Claims Call Center Representative

Job Ref: 59024
Category: Claims
Department: CLAIMS
Location: 160 Water St. #3, New York, NY 10038
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $51,648.00
Salary Range: $51,648.00 - $51,648.00

About NYC Health + Hospitals

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview

MetroPlus Health Plan is looking for an experienced problem solver to join the claims Call Center Team as a Senior Call Center Representative. We need an enthusiastic individual who can listen to customer service claims issues, and offer solutions to each problem, and will be the lead for excellent customer service
delivery to providers via the call center.
The successful candidate for this role will have a strong command of the company’s customer service policies, benefit knowledge for all lines of business, with expertise on all claim types and all aspects of medical claims processing, as well as regulatory and business requirements. The candidate will offer quick and accurate assistance to all customers (external and internal), with the goal of first call resolution. The candidate will work closely with all claims call center representatives to enhance the customer experience and deliver quality outcomes.

Job Description

  • VAnswers incoming customer calls regarding billing issues, claim outcomes, benefit coverage, and general client concerns.
  • Responsible for maintaining a high level of professionalism with clients, and working to establish a positive rapport with every caller.
  • Update real time customer information on all the appropriate applications (e.g. PowerSTEPP, MACESS, etc.).
  • Provides assistance, guidance, and on-the-job training to the claims call center representatives.
  • Responds to complex/difficult inquiries from both internal and external customers in an accurate and timely manner.
  • Assists the claims supervisor with escalated calls.
  • Perform timely and accurate claim adjustments, as required.
  • Obtains necessary information from internal and external customers to determine course of actionrequired to expediently resolve inquiries.
  • Assists in creating process documents and workflows for the call center as needed.
  • Audits work of call center representatives to ensure service level and accuracy, identifying trends and/or training needs.
  • Monitor the ACD queue in the absence of the Supervisor.
  • Work with the management team to stay updated on claims processing criteria, regulatory updates, new benefits and/or products, and be informed of any changes in company policies.
  • Impact the company’s bottom line by problem solving and turning frustrated customers into satisfied customers.
  • Special projects as required.

Minimum Qualifications

  • Four (4) plus years’ experience of medical claims experience required, for all claims types.
  • Thorough Knowledge of Plan Benefits, for all lines of business.
  • Experience with claims processing systems/applications.
  • Experience in PowerSTEPP and MACESS, preferred.
  • 1 to 2 years experience in a call center/customer service industry, a plus.
  • Ability to consistently produce quality work while in a high stress environment.
  • Excellent written and verbal communication skills.
  • Ability to work in close proximity of co-workers, in a team environment.
  • Excellent problem-solving skills.
  • Associates Degree required, or equivalent combination of education/experience.

Professional Competencies:

  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication