Client Services Pharmacy Support Analyst

Position Description

The CS Client Services Support Analyst is responsible to conduct research and provide problem-solving support to the Customer Service Department, Brokers and Sales serving the Small, Large and Major Market Groups as well as our Individual Account plans. Technical and administrative support as well as serving as a liaison to the Vendor contacts in regards to our plan benefits and policy issues. Responsible for reviewing, identifying and analyzing policies, procedures and contract issues that impact both departmental and/or Plan wide functions/operations. Prepare recommendations on all issues; root cause, action steps and monthly reports. This position is responsible for providing efficient, courteous, professional quality service to Groups, Plan personnel and Brokers/Sales in a timely manner. Inquiries are received via Internet, E-Mail and Internal Facets Routing Queues. Ensures compliance with organizational and regulatory requirements. Topics pertaining to enrollment, billing, benefits, and claims for various types of coverage offered by Capital BlueCross- Traditional, POS, PPO, HMO and Medicare Supplemental Programs. Knowledge of Medicare, PPACA, Healthy PA, CHIP, prescription, dental, vision, Chiropractic, Disease Management, Benefits Management, and other programs administered/supported by Capital BlueCross and Avalon.

Responsibilities and Qualifications

Duties and Responsibilities:

• 20% - Researches and reviews customer inquiries as related to one of our Vendor LOB. Determines appropriate action by reviewing and interpreting applicable policies/procedures that are within the established regulatory requirements. Utilizes the PC, manuals, online reference materials, Imaging, etc., to obtain benefits, enrollment and claim information.
• 20% - Ensures the satisfactory resolution of routine and complex Vendor inquiries including, but not limited to, benefits, claim filing and processing, collection issues, enrollment discrepancies, legal requests, Medicare Secondary Payer, Plus Billing and payment requests, Third Party Administrators, COBRA, reinstatements, conversions, refunds, new enrollment, transfer situations, student certifications, handicapped dependents, for all lines of business administered and supported by Capital BlueCross and Avalon. Conducts specific job related instructional sessions as requested by Supervisor.
• 15% - Be able to prioritize work, communicate and share information with the team as necessary. Respond to customers inquiries via telephone, correspondence, on-site, Fax, Secure IT, E-mail and personal interviews from individual customers, group administrators, providers, Capital BlueCross personnel, Host Plan personnel, attorneys, and outside entities working on the customer's behalf.
• 10% - Monitors Vendor related inquiries utilizing various system generated reports for accurate and timely resolution to ensure customer satisfaction and compliance with MTM (Member Touchpoint Measures), PPACA, ERISA, and Act 68 quality, and timeliness guidelines.
• 10% - Provides clear and concise instructions to the appropriate Plan area, in the approved format (e.g., electronic, on-line or hard copy forms, telephone contact) for the resolution of the issues.
• 5% - Contacts the appropriate internal/external entities (e.g., groups, providers, Marketing, Legal, Host Plans, Vendor contacts etc.) to obtain information and initiate necessary action.
• 5% - Enters all information necessary to update the Facets inquiries, Sales Force Case, or Work Desk when appropriate, for tracking inquiry/Sales Force activity and keep notes updated on progress through resolution. Utilizes the system to obtain background information and prevent duplication of effort.
• 5% - Report trends to management that may indicate processing problems, lack of documentation or appropriate information concerning claims, enrollment areas, benefits, policies and procedures.
• 5% - Assists/participates with Marketing personnel and the broker community in the support of customer needs by researching and communicating information to other Company personnel or directly to the customer. May attend or participate in marketing related activities as a representative of Capital BlueCross (e.g., open enrollment, on-site visits, etc.).
• 5% - Performance standards, business metrics and process improvements to include:@@Complete ongoing training to stay abreast of product, service and policy changes@@Improve our quality of work on a daily basis by learning and employing new skills@@Recognize, document and alert the supervisor of trends in customer service inquiries@@Conduct yourself in a manner consistent with the values of the organization.

Skills:

• Demonstrates ability to communicate effectively and professionally both verbally and in writing with all levels of internal/external personnel in order to respond to customer inquiries ranging from routine to complex and involving sensitive subject matter
• Demonstrates ability to understand and interpret detailed policies and procedures and to be able to apply them to various situations. This includes thorough understanding of CBC’s responsibility to maintain privacy of Protected Health Information as required by the Health Insurance Portability and Accountability Act.
• Demonstrates ability to work independently, be flexible and react appropriately to changing job assignments and work environments.
• Demonstrates analytical, organizational, and problem solving skills in order to accurately and efficiently identify, analyze and respond to customer/provider inquiries, as well as identify and analyze trends and discrepancies.
• Familiar with, or ability to, operate a PC and associated software; Microsoft Word, Excel, etc., phone equipment, calculator, fax, copier, and other department required hardware.
• Demonstrated competency in Windows (Outlook, Word, Internet Explorer, Excel and PowerPoint), SharePoint, and Sales Force.
• Above average reading, writing and arithmetic skills required (reading/math comprehension)

Knowledge:

• Knowledge of benefit programs administered and/or supported by Capital BlueCross. Includes Medicare Advantage, Medicare Part D and Medicare Supplemental Programs, Dental, Vision, Chiropractic, Prescription Drug, Benefits Management, and Disease Management.
• Knowledge of the PBM and Facets health plan administration processing systems as well as online files for determining enrollment, billing, and benefits. Knowledge of benefits administration policies, customer billing processes, claims processing and general procedures.
• Knowledge of ERISA, Act 68, and BCBSA MTM,PPACA, HIPAA quality and timeliness guidelines and standards to ensure they are consistently met or exceeded
• Knowledge of Account Administration regulations, policies and procedures pertaining to Capital BlueCross and transfer of enrollment information to all our vendors
• Knowledge of multiple online inquiry systems and coding structures of files to interpret data used in responding to inquiries and Sales Force cases.

Experience:

• 3 years customer service or correspondence experience or experience/training in a writing-intensive role is required.
• *Experience with customer interaction preferred.

Education and Certifications:

• High School degree or equivalent.

Work Environment:

Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions.!!Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.!!Working environment includes typical office conditions.!!Flexible schedules, including nights and weekends, based on business needs.!!Lively and fast paced.

Physical Demands:

While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work 37.5 hours per week. The employee must occasionally lift and/or move up to 5 pounds.

Other:

• Facets, Bridges, Workflow, Share Point, Sales Force, Microsoft Office (Outlook, Word, Excel, PowerPoint, Internet) STARS, CAPS, check reconciliation, Clarity, Business Object, Swift view, delegated administration, RadMD, Blue 2 and Work Desk. The PBM systems. CMS systems.
• Positions may be based in more than one on site location
• Travel@@Amount (% of time)
• Some travel into the office on weekends may be required for training sessions and/or between buildings.