Claims Service Representative

MetroPlus Health Plan - New York, NY (30+ days ago)3.3


Marketing Statement
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
This position is responsible for the accurate and timely response to claim inquiries received from providers and internal MetroPlus departments. Incumbent provides support regarding the adjudication and adjustment of claims for the multiple lines of business. The incumbent works closely with Provider Relations, Medical Management, Member Services and the Claims Processing unit

Job Description
Act as a key liaison and service representative for all provider inquiries and problem resolution.

Respond to all claim inquiries from provider sites personnel including physicians, clinical staff, and site administrators.
Coordinate and track appropriate problem resolution activities with plan personnel in other departments (i.e., claims, utilization management).
Manage and ensure appropriate follow-up and closure for all inquiries.
Data Entry into the IMAX and MACESSsystem.
Perform claim adjustments to correct erroneous payments (overpayments/underpayments).
Participate in Special Projects involving Claim Status Investigations.
Resolve Member Bills referred for Member Services.
Minimum Qualifications
Associate Degree or equivalent combination of education/experience.
Minimum two (2) years’ experience in the healthcare or insurance industry.
In-depth knowledge of MetroPlus Claims Processing protocols and payment schemes.
Thorough knowledge of Plan Benefits.
Adept at managing complex and, at times emotional provider site personnel.
Proficiency in IMAX and TXEN.
Customer Service Experience a plus.
Must be able to handle irate calls in a professional manner.
Excellent verbal and written communications skills.
Excellent PC skills
Professional Competencies

Integrity and Trust
Customer Focus
Functional/Technical skills
Written/Oral Communication
How To Apply
If you wish to apply for this position, please apply online by clicking the "Apply Now" button or forward your resume, noting the above Job ID #, to:

MetroPlus Health Plan
Human Resources Department
160 Water Street 8th Floor
New York, NY 10038
Attn: Recruitment Unit

This is a unionized position, in addition to a variety of options for Health Benefits through MetroPlus, unionized employees are eligible for vision, dental, life insurance, prescription drug coverage and more through their designated union.