RETIREE HEALTH INSURANCE COUNSELOR

About The Company

PEHP Health & Benefits is a division of the Utah Retirement Systems that proudly serves Utah’s public employees through high quality and competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis. As a government entity, we embrace both a public mission and a commitment to creating customer value, excelling in the market, and improving healthcare. We offer a competitive salary with generous benefits, personal development in a positive team environment, and excellent work-life balance.

For most jobs, remote work is available for 9 out of every 10 workdays.

Job Description

POSITION SUMMARY

Plays a critical role in PEHP’s efforts to serve and create value for our members by helping them understand their benefits, avoid payment surprises, navigate healthcare complexity, resolve problems, and confirm members are properly enrolled in PEHP products for Medicare, Medicare Supplement, the Health Exchange, and COBRA. Performs a variety of duties to handle incoming calls, faxes, emails regarding claims, eligibility, verification of benefits, limitations and exclusions, and enrollment for all PEHP plans. Successful performance for the position requires a genuine interest in helping others, the ability to learn and share complex information about health benefits, maintain accurate and timely records for members and employer groups, and a high level of commitment and dependability.

ESSENTIAL JOB FUNCTIONS AND DUTIES

• Receives, responds, and advises incoming phone calls from policy holders, claimants, providers, and insurance companies. Performs a variety of duties as needed to respond to complex questions regarding claims processing, policy descriptions and interpretations, payment processes, coordination of benefits, eligibility for covered services, appeals and prior authorization/pre-notification, corrections, enrollment, and premium questions.
• Provides individualized, custom education to callers on Medicare, Medicare Supplement, and the Health Exchange. Assists members in selecting, understanding, and utilizing their benefits.
• Documents benefit quotes and other information given to members to serve as an accurate record of what was communicated.
• Interviews, meets, and counsels members on the phone and in person regarding eligibility in PEHP retiree health plans, employer paid health benefits, and Medicare related questions. Assists in completion of application forms. Initiates related premium billing or deduction plans. Verifies that retiree enrollment information is authorized by the employer group. Educates current and prospective retirees on the benefits of PEHP Medicare and Medigap plans, coordination of benefits, the Health Exchange, and premium billing process. Makes outbound calls to potential Medicare Supplement members to inform them of PEHP’s products and enrolls them in Medicare Supplement plans.
• Processes member enrollment and change forms, including data entry into the PEHP system. Requests and verifies information as needed to expedite enrollment.
• Performs comprehensive monitoring of benefit payments (eligibility, premiums, billing) to assure proper credit to employer groups and members. Monitors payroll deduction reports to ensure accuracy. Performs online updates to State payroll system (SAP) to begin, adjust, or cancel deductions as needed.
• Coordinates billing/refund issues within the department and with Accounting staff, researching applicable reports to verify and process premium refund requests and third-party vendor payments.
• Performs complex and technical aspects of enrollment and maintenance of special programs such as early retirements and Medicare supplement plans. Processes periodic EDI/flat enrollment/change files from brokers and employees, ensuring transactions are valid and complete. Researches and processes monthly reports to verify active employment terminations, transitions to Medicare, or other status changes. Mails letters and appropriate enrollment forms to prospective and current retirees, notifying them of premium changes, plan termination, or status change. Processes, verifies, and speaks to employer groups regarding ACA employer files.
• Maintains enrollment process documentation for department use, reference, and training. Maintains accurate and accessible filing system for non-imaged reports and forms.
• Performs the duties of their position at a consistently high level of quality with minimal assistance from team lead(s) or management.
• Maintains regular and reliable attendance.
• Maintains strict confidentiality.
• Perform special projects and other related duties as needed.

Required Experience

Education and Experience

High School diploma or equivalent and two (2) years experience within the insurance industry performing a variety of duties related to processing of enrollments, employment status, changes and premium collections of group insurance members; and one (1) year of PEHP experience is required; or an equivalent combination of education and experience.

Specific experience within the insurance industry enrollment and claims processing is preferred.

Knowledge, Skills, and Abilities

This list contains knowledge, skills, and abilities that are typically associated with the job. It is not all-inclusive and may vary from position to position:

Required technical skills include the working knowledge and ability of:

• Computer operations and technical software applications.
• Microsoft Office Suite.

Required mathematical skills include working knowledge of

• Addition, subtraction, multiplication, and division in all units of measurement, using whole numbers, common fractions, and decimals.

Must possess excellent communication skills

• Communicate effectively in writing and verbally.
• Establish and maintain effective working relationships with supervisors, managers, co-workers, and the public.

Required working knowledge of

• Health insurance benefits provided by Medicare, PEHP Medicare Supplement, and the Federal Health Exchange.
• Claims adjudication policies, procedures, and processes.
• Intricacies related to medical, dental, pharmacy, medical coding, and medical terminology.
• Purposes, principles and practices of public insurance systems.
• Insurance laws and IRS filing requirements regarding the Affordable Care Act (ACA).
• General office practices and procedures.
• Alpha and numeric recording systems.
• Customer service, telephone etiquette, and bookkeeping.

Must have the ability to

• Analyze a variety of complex claims management issues and make corrections.
• Follow written and verbal instructions.
• Work independently and deal effectively with stress caused by work load and time deadlines.
• Document calls accurately and succinctly.
• Interpret medical claims, prior authorizations, and appeals.

The incumbent must always demonstrate judgment, high integrity, and personal values consistent with the values of URS.

Work Environment

Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing and seeing. Common eye, hand, finger dexterity required to perform essential functions.