Beneficiary Care Representative - UMWA Health and Retirement Funds : Job Details

SUMMARY

The purpose of this position is to answer effectively and efficiently a wide range of complex beneficiary health, eligibility, and pension questions, both verbally and in writing, ensuring Funds' benefits and policy information is delivered in a professional and courteous manner, consistent with Funds' performance standards.

ESSENTIAL DUTIES AND RESPONSIBILITIES including the following:

Health Benefits Responsibilities

Must be knowledgeable of all 12 health plan variations, which include differences in deductibles, copayments, hospital coinsurance, provider networks, Coordination of Benefits (COB), Affordable Care Act (ACA) rules, prescription maintenance choice, prescription copay waiver program, prescription cost differences and surcharges under the preferred product program, routine vision benefits, and plans with dental benefits. Must be knowledgeable of all complexities of the Funds' Health Plans.

Applies knowledge of Medicare regulations (including specific coverage rules for all types of benefits, deductibles, coinsurance, maximums & exclusions), Veterans Administration claim payments, and Department of Labor (DOL)/Responsible Mine Operator (RMO) payments and guidelines for Black Lung benefits to calls handled.

Must understand which laws/rules are applicable based upon the Retiree, Grandfathered and Non-Grandfathered status of the various health plans, such as the Affordable Care Act, Mental Health Parity and Addiction Equity Act, Women's Health and Cancer Rights Act, Coverage of Preventive Care without Employee Cost-sharing, Nondiscrimination rules, Wellness Program requirements, Prohibition on Annual Limits, Prohibition on Rescissions, and Dependent Coverage to Age 26.

Responsible for handling Coordination of Benefits (COB) documents, forms, and spreadsheets that are received or generated for the purpose of identifying, advising, and documenting other insurance information. Determines the Order of Benefits to process medical, dental, vision and prescription drug claims. Works closely with the claims vendors to ensure accurate processing of COB claims, including the review of Medicare Parts A and B and other plans such as the Medicare Advantage Plan, HMOs, PPOs and Medicare Part D prescription drug plans.

Responsible for identifying and handling complex Dual coverage COB issues for beneficiaries with multiple Funds benefit plans and explaining the processing of these claims to beneficiaries, providers, and UMWA representatives. Must provide a high level of knowledge in determining Order of Benefits and have the ability to differentiate between rules that apply in the coal industry versus the traditional COB methods. Notifies claims vendors of necessary corrections to COB indicators and claims adjustments, resulting in correct payments by the primary and secondary payers, and ensuring the beneficiaries are receiving their entitled level of benefits

Responsible for handling complex COB issues arising from mineworkers and UMWA representatives who are actively working and have Medicare benefits. Notifies claims vendors of necessary corrections of COB indicators, Medicare indicators and claims adjustments.

Participates in periodic Medicare Audits, making a high volume of outbound calls to providers requesting medical documentation to support the payment of the claim. Performs initial quality review of claim documentation and claims system screen prints during the claims payment portion of the Medicare audit. Collaborates with clinical reviewers, consultants, and healthcare providers to update and organize PDF documents and obtain medical records, documentation and record notes during the clinical review portion of the Medicare audit.

Resolves beneficiary and provider disputes over claims payment practices or reimbursement amounts, informing them of Funds' benefits, practices, and policies, and arranging for reprocessing of claims or payment adjustments when appropriate.

Researches and resolves health claim inquiries from beneficiaries, providers, UMWA representatives and coal company representatives. Provides a high level of review, adhering to Funds' policies and procedures, Medicare regulations, medical claims processing system, and medical management system, as necessary. Works closely with claims vendors, providers, and other health insurance carriers, as necessary. Researches and applies knowledge of medical claims coding (all standard coding guidelines and forms).

Researches prescription drug claims for beneficiaries with medication issues in the Caremark claims system to determine why a claim was denied or when higher patient responsibility must be applied. Responsible for resolving issues directly with Caremark Client Services or placing drug overrides in claims system in certain circumstances and notifying beneficiary of outcome, resulting in real-time assistance to beneficiaries often while the beneficiary is at the pharmacy, allowing the beneficiary to pick up his/her medication without disruption, using advanced knowledge of all Funds' Prescription programs and coverage, which includes basic knowledge of drug names and drug classes.

Identifies provider relations issues that may impact beneficiaries and refers them to the Provider Representative, working closely with the Provider Representative staff to maintain a continuum of care for beneficiaries, if providers force upfront payments, balance bill Funds' beneficiaries, turn beneficiaries over to collections, refuse services to beneficiaries, make legal filings against Funds' beneficiaries, and/or bill fraudulent services.

Responsible for guiding beneficiaries through the processes related to Hold Harmless protection. Includes attempts to resolve claims issues before Hold Harmless is initiated by contacting providers in writing to resolve balances in excess of Funds' fee limits or non-medically necessary services. Initiates Hold Harmless protection when a beneficiary is turned over to collections by the provider by notifying the beneficiary and provider/collection agency in writing and advising the provider to cease collection activity. Includes assistance with court summons and credit issues resulting from steps taken by providers to collect on Hold Harmless balances, while working with the Funds Hold Harmless Coordinator.

Customer Service Responsibilities

Counsels and provides a strong level of knowledge to beneficiaries, applicants, UMWA representatives, healthcare providers, collection agencies, claims' vendors, coal company representatives, government agencies and other interested parties regarding the rules, regulations, policies, and procedures governing the Funds' health and pension benefit plans including, but not limited to, eligibility requirements, payments, available programs, and outreach.

Demonstrates expertise in operating call center telephone system and related call tracking/customer service software applications, Funds' internal eligibility software, vendor claims processing systems as well as various other databases and websites. Demonstrates ability and skill to use copiers, scanners, printers, and other general office equipment.

Advocates for beneficiaries and mine workers in resolving issues relevant to other agencies such as Medicare, Medicaid, Black Lung, Health and Human Services, and Housing Authorities. Provides requested income verifications for beneficiaries to qualify for services provided by these entities.

Performs outreach activities to educate potential applicants, beneficiaries, and other interested parties about Funds' benefits, eligibility requirements, and the application process. Makes outbound phone calls in support of education campaigns. Must research extensively to locate beneficiaries and obtain critical information in order to maintain pension and health benefits. Includes researching documentation in all claims and eligibility systems as well as reaching out to providers, pharmacies, banks, and other entities, as necessary.

Identifies, reports, and resolves a variety of problems, applying high-level knowledge of complex benefit plans while counseling applicants in person, in writing, or by telephone.

Responds to pension, health and eligibility questions from applicants, beneficiaries, UMWA representatives, coal company representatives, and other interested parties.

Records updates or corrections of information in Funds' electronic records as well as the Funds' call tracking system to record the receipt and ultimate disposition of inquiries while maintaining at all times the confidentiality of coal company, provider, and beneficiary records.

QUALIFICATIONS

To perform this job successfully an individual must be able to perform each essential duty satisfactorily, sometimes under stressful situations, including the handling of multiple job-related tasks. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE

• Completion of community college or vocational school with a customer service track or certificate program PLUS one year of prior customer service experience utilizing oral and written communication skills, working with people to provide assistance or resolve problems, answering high volume of telephone calls, and interpreting complex regulations, policies, and procedures.
• OR A high school diploma or General Education Degree (GED) plus two years of prior customer service experience, utilizing oral and written communication skills, working with people to provide assistance or resolve problems, answering a high volume of telephone calls, and interpreting complex regulations, policies, and procedures.