Address
Form of workQuality Control Reviewer III Requisition #: 6466 Category: Bargaining # of openings: 1 Location: New York, NY Fund: 1199SEIU Benefit and Pension Funds Pay Range: $52,263.64 Department: Appeals Work Hours: M - F, 9:00 a.m. to 5:00 p.m. Position Status: Permanent Workplace Arrangement: Hybrid Employment Type: Full time
Description Responsibilities
Optimize 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 m onitoring 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 resolution
Access 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 for all 1199SEIU Family of Funds.
Collaboratively communicate final disposition of appeal request with members, providers, vendors, authorized representatives, and other professionals via written correspondence
Maintain 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 1199SEIU 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 System
Act 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 DMS
Perform other duties and assignments as directed by management
Qualifications
High 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.) required
Two years of Claims processing experience required; extensive knowledge of medical terminology preferred
Comprehensive knowledge of 1199SEIU Benefit and Pension Fund eligibility guidelines, benefit entitlements, plan rules, across the 1199SEIU Family of 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 rate
Demonstrated 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 skills
Bi-lingual Spanish preferred
We offer extraordinary benefits including outstanding health, dental, pension and family benefits for most positions which are paid entirely by the Funds without co-payments, deductibles, or out-of-pocket expenses for covered services. We also offer tuition reimbursement, generous holiday, vacation, and sick leave, as well as a 401K plan.
Previous Applicants: Email: Password:
If you do not remember your password click here.
Back to Search Results
New Search
