Claims Call Center Representative

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

MetroPlus Health Plan is looking for an experienced problem solver to join the Claims Operations Call Center team as a Customer Service Representative. We need an enthusiastic individual who can listen to customer service issues, offer solution to each problem.
The successful candidate for this role will have a strong command of the company’s customer service policies, benefit knowledge for all the lines-of-business, is knowledgeable on all claim types and all aspects of medical claims processing as well as regulatory and business requirements. Candidate can be critical for offering quick and accurate assistance to customers with the goal for first call resolution. The candidate will work closely with external and internal customers to enhance the customer experience and deliver quality outcomes.

• Answers incoming customer calls regarding billing issues, claim outcomes, benefit coverage, and general client concerns.
• Responsible for maintaining a high level of professionalism with clients and working to establish a positive rapport with every caller.
• Update, real time, customer information on all the appropriate applications (e.g. PowerSTEPP, MACESS, etc.).
• Coordinate, follow-up and track appropriate problem resolution activities with all appropriate staff to ensure timely resolution.
• Perform timely and accurate claim adjustments, as required.
• Participate in ‘Special’ projects as required.
• Work with the management team to stay updated on claims processing criteria, regulatory updates, new benefits and/or products and be informed of any changes in company policies.
• Impact the company’s bottom line by problem solving and turning frustrated customers into contented customers.

• Four (4) plus years’ experience of medical claims experience required, for all claim types.
• Thorough knowledge of Plan Benefits, for all lines-of-business.
• Experience with claims processing systems / applications.
• Experience in PowerSTEPP and MACESS, preferred.
• 1 to 2 years’ experience in the call center / customer service industry, a plus.
• Excellent verbal and written communication skills.
• Ability to consistently produce quality work while in high stress situations.
• Ability to work in close proximity of co-workers, in a team environment.
• Good problem-solving skills.
• Associate degree required (bachelor’s degree, preferred).

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication