PEHP Health & Benefits is a division of the Utah Retirement Systems that proudly serves Utah’s public employees through high quality and competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis.   As a government entity, we embrace both a public mission and a commitment to creating customer value, excelling in the market, and improving healthcare.   We offer a competitive salary with generous benefits, personal development in a positive team environment, and excellent work-life balance.

POSITION SUMMARY

Plays a critical role in PEHP’s efforts to serve and create value for our members by helping them understand their benefits, avoid payment surprises, navigate healthcare complexity, resolve problems, and make good benefit decisions.  Performs a variety of duties to handle incoming calls, faxes and emails regarding claims, eligibility, verification of benefits, limitation and exclusions and website related questions, for all PEHP plans. Documents all communications.   Successful performance for the position requires a genuine interest in helping others, the ability to learn about and share complex information about health benefits, and a high level of commitment and dependability.

ESSENTIAL DUTIES & RESPONSIBILITIES

1. Receives and responds to incoming phone calls from policy holders, claimants, providers, and representatives of other insurance companies.  Responds to complex questions regarding claims processing policy descriptions and interpretations, payment processes, coordination of benefits, eligibility for covered services, appeals and prior authorization/pre-notification, enrollment and premium questions. 
2. Greets the public; meets with policyholders/claimants regarding medical and dental issues; benefits, claims and payment status; responds to questions regarding claims process, policy descriptions and interpretations, payment process, eligible or covered service.
3. Educates members and providers on website tools and navigation.  Troubleshoots website account issues including setup, password resets and deletions along with other various website issues. Assists members in making changes through the website.
4. Identifies erroneous claims adjudication, member enrollment, prior authorization/pre-notification in a timely manner, including processing of any research and correction requests. 
5. Makes outgoing phone calls to assist members and providers in submitting  information necessary to assist in benefit utilization, claim processing, completion of preauthorization requests and appeals.
6. Provides walk-in clients with requested forms, publications and other informational materials. Directs walk-in clients and visitors to proper office locations; apprises staff of appointment arrivals.  Listens to client complaints, questions, etc. and responds to member requests to mail forms.
7. Provides clerical/secretarial support to various departments; writes and delivers messages to personnel; signs for incoming mail; distributes mail or notifies appropriate personnel of mail delivery; contacts mail carriers for package pick-up.  Assist Enrollment Specialists and other departments with collection of premium payments; advises members of premium obligations; mails member statements, verification forms, etc; returns incomplete forms. 
8. Receives enrollment forms. Checks for accuracy and completeness.  Interprets PEHP policies for walk-in clients regarding pharmacy and medical medications to determine coverage for retail, mail-order and specialty medications.  Serves as a resource to help resolve pharmacy issues pertaining to pre-authorizations; appeals; eligibility; mail-order issues; benefit interpretation; coordination of benefits and claims payments.  Coordinates with the Pharmacy department regarding pre-authorizations, appeals, vacation overrides, pay-and-educate, 90+ agreements, and new policy/procedure implementation.
9. Advises callers in the proper procedures related to claims processing, corrections and appeals.
10. Receives and responds to incoming faxes and emails. Utilizes a variety of computer resources and tools to obtain proper and accurate information related to specific questions.
11. Documents benefit quotes and other information given to members to serve as an accurate record of what was communicated.
12. Maintains strict confidentiality.
13. Performs other related duties as required.

Coordination of Benefits Responsibilities

1. Researches and updates coordination of benefits information for policy holders/dependents with multiple insurance coverage. Corresponds with members to verify and confirm coordination of benefits information. Analyzes documentation and state/national coordination of benefits guidelines to accurately determine coordination of benefits order in a variety of complex situations. Provides written confirmation of Coordination of Benefits changes to policy holders based on updates and changes. Sends written requests for information to policy holders as necessary.
2. Receives and responds to inbound phone calls from internal Customer Service Reps, other PEHP and URS departments, policy holders/dependents, providers, and representatives of other insurance companies regarding coordination of benefits issues and concerns. Makes outbound phone calls to policy holders, providers, and other insurance companies to verify coordination of benefits information. Calls members to determine out of state residency status at the request of the claims department.  Provides walk-in customers with assistance in regards to coordination of benefits concerns and issues at the request of members.
3. Reviews claims as requested by the claims department for Coordination of Benefits changes and updates.  Notifies the appropriate departments of impacts when Coordination of Benefits changes/updates are made.  Processes a high volume of inbound mail, faxes, emails, etc. to maintain a prompt turnaround of information and ensure the accuracy of claims and benefits.
4. Analyzes a variety of reports to maintain current COB information on PEHP policy holders and identify future COB changes or issues in a timely manner. Prepares COB documentation for imaging.

Education and Experience

High School Diploma and one (1) year of progressively responsible experience performing a variety of duties relating to customer service; OR an equivalent combination of education and experience.

Specific experience in health insurance call centers, customer service, or claims adjudication, preferred.

Knowledge, Skills, and Abilities

Requires considerable knowledge of claims adjudication policies, procedures and processes; intricacies related to medical, dental, pharmacy, mental health, home health, chiropractic claims, and Medicare Supplement claims; medical terminology; various office management systems related to alpha and numeric record keeping; interpersonal communication skills; public relations skills; telephone etiquette; personal computer operations (PC/MS) and various  program applications; basic bookkeeping; negotiation techniques; some knowledge of 10 key operation; basic mathematics.

Must have the ability to analyze a variety of claims management issues and problems and make corrections; communicate effectively verbally and in writing; ability to follow written and verbal instructions; establish and maintain effective working relationships with professionals, executives (public and private) department heads, co workers and the public; work independently and deal effectively with stress caused by heavy workload and handling difficult or irate phone calls.  Must be able to document calls in computer accurately and succinctly.  Must be able to interpret medical and other words related to claims, prior authorizations and appeals.

Work Environment

Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing and seeing. Common eye, hand, finger dexterity required to perform essential functions.