Claims Examiner

Quality Control Reviewer/Claims Examiner - Appeals DepartmentResponsibilitiesOptimize work processes to investigate, research, and gather information regarding member appeals and provider inquiries by analyzing and investigating all issues involved and working with applicable departments in accordance with the Fund’s policies, guidelines, and DOL regulations.Ensure accountability by monitoring caseload daily to ensure all requests are kept within compliance, includes, but is not limited to; maintaining accurate, timely, and complete record of appeals in the Appeals Tracking System (ATS); Documenting all correspondence with members/dependents or authorized representatives (e.g., providers, vendors, etc.); following-up and escalating when compliance standards are at risk to assure timely disposition & swift resolutionAccess QNXT Claims processing system, such as Claims, Memos/Alerts, UM Documents, Provider Summary, DMS, etc.), V3 (Vi-Tech), third party vendors, (e.g., eviCore, Care Continuum, etc.) to determine eligibility guidelines (e.g. COB, COBRA, etc.), benefit entitlements, and plan rules related to the appeals.Collaboratively communicate final disposition of appeal request with members, providers, vendors, authorized representatives, and other professionals via written correspondenceMaintain HIPAA compliance while communicating (via inbound and outbound calls) with members, providers, authorized representatives, other healthcare professionals regarding appeals processes, Fund benefits, policies and procedures, plan changes for all benefits and programs (including but not limited to NBF, GBF, HCF benefit and Pension, CCF, TEF, etc.); Document and resolve all Appeals related telephone inquiries (i.e. with members, dependents, providers, etc.) in the QNXT Memos/Alerts and Call Tracking SystemAct as liaison between members/dependents or authorized representatives (e.g., providers, vendors, etc.) and internal Fund departments to resolve complex issues.Identify trends and report results to management.Maintain various logs, i.e. daily phone logs, weekly/monthly productivity reports and other statistical reports, as necessary.Index and Archive documents/files electronically in DMSPerform other duties and assignments as directed by management.QualificationsHigh School Diploma or GED required; some college or degree preferred.Minimum three (3) years’ experience with the Funds processing/management systems (e.g., QNXT (Claims, Providers, Utilization Management, Memos/Alerts), Appeals Tracking System (ATS), etc.) and web-based applications/systems (e.g. Eligibility (V3), Data Management Systems (DMS), Right Fax, etc.) requiredTwo years of Claims processing experience required; extensive knowledge of medical terminology preferred.Comprehensive knowledge of Fund eligibility guidelines, benefit entitlements, plan rules, across the Funds and knowledge of benefits required.Must possess the skills to navigate between multiple screens/systems to keep members fully engaged and manage call time, while quickly and accurately responding to inquiries and data entering relevant notes with a minimum 6,000 KPH and 6% or less error rateDemonstrated organizational and time management skills with ability to prioritize, multi-task, follow up and follow through on assignments, while working under pressure to meet deadlines in a fast-paced environment.Advanced PC skills with knowledge of Microsoft Word, Excel, and Outlook required.Knowledge of eligibility guidelines, QNXT claims processing system (claims history, patient notes, etc.) and programs for all three Funds desirable.Excellent communication skills – oral, written and listening; excellent interpersonal skills including courtesy, tact and discretion. A positive “can-do” attitude. Ability to use positive language.Demonstrated ability to meet quality and productivity standards; excellent problem solving and analytical skillsBi-lingual Spanish preferred