Health Advocate

Insurance

• Resolve Complex Claims Issues: Investigate billing discrepancies, identify errors, and coordinate resolutions among members, carriers, and providers for timely claim processing.
• Coordinate Benefits Across Carriers: Manage cases involving Medicaid, Medicare, motor vehicle claims, and other benefit programs, ensuring proper coordination.
• Educate and Empower Members: Help members understand their benefit plans, educate them on coverage details, and guide them through challenging claims scenarios.
• Ensure Accuracy: Adhere to internal policies, procedures, and federal regulations to process claims in a precise and timely manner.
• Collaborate and Escalate: Partner with team members and escalate unresolved issues to supervisors or carriers when necessary.
• Support Team Growth: Mentor new team members, share best practices, and contribute to continuous process improvements.

Claims Specialist

Research Analyst

• Responsible for researching and understand websites and reference materials regarding the healthcare system; provide information to nurses regarding providers, eldercare, nursing homes and other requested information; respond to member requests by providing specific resources and options; track cases and follow-up with members and providers in a timely manner\n• Research Functions – Research and understand websites and reference materials regarding the healthcare system ensuring adherence to department and corporate policies and procedures\n• Research and document request information (e.g., primary care physicians, dentists, etc.)\n• Identify appropriate benefit plans for benefit offerings\n• Provide information to advocates regarding providers, eldercare, nursing homes and other requested information\n• Respond to member requests by providing specific resources and options\n• Enter all required documentation into the system and ensure its accuracy\n• Ensure research results are compiled in a user friendly format for members to review and respond\n• Track cases and follow-up with members and providers in a timely manner\n• Exercise exceptional customer service skills in an effort to optimize each contact with the member\n• Ensure that calls are processed in strict adherence to established policies, procedures, quality standards as well as applicable federal laws and regulations\n• Know and support approved departmental and corporate policies and procedures relating to benefit issues\n• Ensure policies and procedures are in compliance with all applicable laws and regulations, including the privacy of employee health information in compliance with federal and state laws such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)\n• Healthcare System Research Assistance - Assist in resolving routine research issues by identifying issue(s) and researching in a timely manner *Follow research through until resolution *Document all issues thoroughly maintaining department files or appropriate system *Continuously evaluate the status of all work efforts, ensuring all tasks are prioritized to assist in providing timely and quality services *Assist in monitoring issue trends, escalating such trends to supervisor to determine appropriate actions necessary to eliminate future occurrences and improve service levels\n• Team Interfaces/Customer Service - Establish and maintain a professional relationship with internal/external customers, team members and department contacts * Cooperate with team members to meet goals or to complete tasks * Provide quality customer service that exceeds customer expectations and improves level of service being provided * Treat all internal/external customers, team members and department contacts with dignity/respect * Escalate to supervisor any situation outside the employee's control that could adversely impact the services being provided\n• Mental and Physical Requirements *This position will be exposed mainly to an indoor office environment and will be expected to work near or around computers, telephones, and printers *The nature of the work in this position is sedentary and the incumbent will be sitting most of the time. *Essential physical functions of the job include fingering, grasping, pulling hand over hand, and repetitive motions to utilize general computer software/hardware continuously throughout the work day *Essential mental functions of this position include concentrating on tasks, reading information, and verbal/written communication to others continuously throughout the work day

Claims Specialist

Research Associate