Health Plan Representatives

Title: Health Plan Representatives (This is more of an inbound call center role)

Remote (Denver, CO - Initial start date would be in person all day to pick up equipment and check system accessibility other wise remote)

Duration: 13 weeks contract with strong possibility of extension

Role 8 hour days M - F

Job ID : 11571312

Education: High School Diploma or GED Required

Work Experience: 1-3 years Health Plan or customer service experience. Required

Job Description/Job Summary:

• Under general supervision, assists with the day-to-day operations of the Denver Health Medical Plan. Identifies, researches, and resolves complex problems by assisting members and providers in resolving their health plan related issues. Effectively makes decisions regarding whether member or provider information meets requirements for programs when circumstances require exceptions from, or interpretations of, rules, regulations or policies. Follows escalation procedures, and assists with documenting and tracking appeals and grievances. Collaborates directly with both internal and external partners such as State entities, other departments and community organizations.
• Essential Functions: Identifies, researches, and resolves complex problems related to health insurance benefits, eligibility, utilization, authorizations and claims by assisting members and providers in resolving their issues. (10%) Communicates and explains health plan benefits, EOBs, RAs and claims data (10%) Actively identifies programmatic and technical (system) issues and recommends and implements solutions to those challenges. (10%) Receives, processes and verifies health premium payments. (10%) Identifies appropriate solutions and involves others in the implementation process. (10%) Communicates member and provider communication trends and recommendations with department leadership. (10%) Effectively makes decisions regarding whether member or provider information meets requirements for programs when circumstances require exceptions from, or interpretations of, rules, regulations or policies. (10%) Follows escalation procedures, and assists with documenting and tracking member and provider appeals and grievances. (10%) Collaborates directly with both internal and external partners such as State entities, other departments and community organizations. (10%) Collects data utilizing various tracking tools that have been developed to monitor performance. (10%)

Knowledge, Skills and Abilities:

Knowledge of health care administration, including managed care, Medicaid, Medicare, Exchange and CHP+ eligibility and enrollment policies and processes. Knowledge of federal and Colorado statutes, legislative initiatives and regulations, as well as federal, state and local policies. Skilled in analytical thinking, problem solving, and process improvement. Skills in providing excellent customer service. Ability to communicate effectively.

Ability to disseminate program information, policies, rules and/or regulations. Ability to simultaneously coordinate and manage several functions, programs, and projects in various stages of completion. Ability to consistently implement program, department and organizational policies and procedures. Ability to work in teams to get projects done, and to work with those at all levels of the organization.

Knowledge of PC applications, specifically Microsoft Office products, and the ability to learn new computer applications. Knowledge of health plan information systems, preferably QNXT and MMIS.

Roles are expected to be 40 hours per week, with the exception of our department closures/holidays The initial start date would be in person all day to pick up equipment and check system accessibility other wise remote.