The FEP Benefit Processor/CSR II is responsible for making accurate and timely claims processing determinations on medical and dental claims. This position is also required to maintain servicing proficiency to assist our Members and Providers by telephone, in-person, and written correspondence.

Expected servicing requirements include accurate and timely claims processing and servicing of inquiry to ensure a level of satisfaction that meets or exceeds our FEP contractual performance requirements.

Work directly impacts the quality and cost of work in the department and contributes towards HMSA's mission to deliver exceptional service and outstanding results to our customers.

Thorough working knowledge of standard and non-routine procedures, products, rules and instructions to perform full range of assignments. Requires complete analysis, reasoning and problem solving to research, identify and resolve recurring inefficiencies that may involve system issues, enrollment, benefits and claims processing information and procedures. Applies judgment to discern relevant information, and to recommend best precedents, guidelines or options.

• Perform accurate benefit administration determinations on standard and complex claims processing scenarios that meet accuracy and timelines standards. Concurrently utilize multiple local HMSA and FEP Director's Office and Operations Center systems and resources to research and resolve claims processing deferrals and adjustments.

  • Effectively apply sound claims processing decisions that deliver high quality customer-centric delivery of service.

  • Collaborate with intra-department team and internal departments that support FEP benefit and claims processing activities such as Medical Management, Customer Relations and Finance & Accounting to ensure consistent delivery of information and services.

• Identify problematic issues in policy or process that result in unintended negative consequences for the Member or Provider. Promptly present case details, recommend solutions, and/or corrective action to management to minimize unfavorable customer impact.

• Deliver accurate and timely responses to eligibility, benefit and basic/complex claims status inquiries using multiple systems and resources to research information (i.e., QNXT, Documentum, 837 Database, Mainframe, ASSIST, FEPDirect, FEPBlue.org, BlueWeb.org, PC software). Exhibit advanced ability to respond verbally, in person and in writing to internal and external customer's inquiries on enrollment, eligibility, benefits and claims adjudication questions in a professional, accurate and timely manner.

• Active and engaged participation in test claim creation and validation efforts to ensure the proper processing outcomes and compliance with local HMSA and FEP Operations Center system upgrades and / or enhancements.

• Performs all other miscellaneous responsibilities and duties as assigned or directed.