Duties Note: The following is not intended to be an exhaustive list of all duties required of this position.
ADA
E1. Responds to and resolves inquires from subscribers, members, providers, facilities, other Blues plans: •Communicates and interacts with customers in a written or verbal manner in a clear, unambiguous, concise, professional and empathetic fashion. •Handles all inquiries and services incoming and outbound calls and correspondence. •Considers all aspects or elements in a logical manner; considers contractual provisions and options to resolve inquiry; communicates with other Blues Plans, providers and other service areas throughout the Corporation. •Utilizes and interprets appropriate reference materials and other necessary resources in responding to inquiries. •Communicates with internal and external customers via phone, personal contact (lobby walk-ins), email, online chat or in writing; utilizes Letter Reference Guide (LRG) templates as necessary. •Takes ownership of problems and establishes relationships with all customers meeting all corporate guidelines. •Demonstrates an ability to communicate the contract benefits and requirements to the customer; communicates various plan benefit differences. •Identifies potential problems and inconsistencies, recommends and forwards to Sr. Representative and/or management for solution. •Assists with compiling data, provides necessary support to resolve cases.
E2. Processes and adjusts claims processed through the BlueCard Program: •Performs online transactions and/or adjustments for claims processed via the Blue Card Program. •Determines claim disposition by reviewing correspondence, Host coordination of benefits (COB) information, and claim inquiry history; follows desk levels, standard operating procedures and COB guidelines. •Researches, tracks, and follows up on information regarding claim benefits, eligibility and all other aspects of business. •Updates appropriate systems to reflect accurate information. •Identifies potential fraud cases and forwards to Special Investigations Unit.
N3. Performs all job duties efficiently, accurately and at an acceptable rate of performance.
N4. Performs related clerical duties: •Faxes, copies documents.
E5. Maintains confidentiality and adheres to HIPAA regulations.
E6. Delivers customer service in a professional, polite and efficient manner.
N7. Performs other duties of similar nature that are necessary and not inconsistent with this position or this pay grade.

Education/Experience/Skills Requirements
Required Education:
HS/GED:

Required Experience:
One year customer service, contact center, or healthcare related experience as demonstrated by proficiency in one or more of the following areas: claims processing, adjusting or membership processing is required. Two (2) years Customer Service related experience in a high volume call/contact center is preferred.

Required Knowledge/Skills:
1. Must meet qualifications to perform the job including satisfactory completion of all training and testing
2. Customer Service Representative tests - passing score
3. Ability to multitask in fast paced service environment
4. Well organized with ability to adapt to changing office environment; exhibits attention to details and time management skills
5. Proficiency in English language skills, including spelling, punctuation and grammar, in both written and verbal communication to ensure communications are issued in a professional manner
6. Ability to effectively communicate in both written and verbal communication with internal and external contacts, in a professional manner
7. Working knowledge of personal computer and application software such as Microsoft Office
8. Ability to utilize basic office equipment including PC, scanner, telephone, copier, printer, fax, calculator
9. Computer Software typically used: Facets/Streamline, PEGA/PRPC, Content Manager, Blue 2
Required Licenses/Certifications:
Problem Solving
Identifies problems and inconsistencies; recognizes major issues, identifies key facts; Seeks information.
Managerial/Supervisory Responsibilities
Does this Position have Supervisory Responsibility? No
Number of Emps Supervised:
Titles of Employees Supervised:
Financial/Budgetary Responsibilities:
Other Job Specifications:
External Contacts: Members, Providers, other Blues plans
Working Conditions/Physical Demands:
Position requires:
* Must be able to work in an office environment
Position involves:
* Physical Effort: Minimum; typical of most office work. Mostly sedentary work.
* Weight: lift/carry/push/pull under 10 lbs.
* Prolonged Sitting
* Repetitive Motion
* Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
* Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
* Vision Req: Close vision (clear vision at 20 inches or less)

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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