ESSENTIAL DUTIES AND RESPONSIBILITIES

including the following: 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. Works with beneficiaries to locate Funds' Cooperating providers, Preferred Provider List (PPL) providers, Private Healthcare Systems (PHCS) providers, Hearing Aid, and Durable Medical Equipment (DME) providers who are located in areas in which beneficiaries live. Providers are identified by searching the Funds Provider Portal, Hearing aid list, and DME provider lookup site. Answers inquiries related to providers who may be Medicare Sanctioned, Medicare Opt-Out, or Medicare Non-Participating providers. Also explains how both Medicare and the Funds process claims for these providers. Responsible for guiding new Funds' beneficiaries to the use of network DME providers via outbound phone calls and during routine incoming calls, which avoids rejected claims for use of non-network DME providers. Works with the Funds' DME vendor manager to resolve DME billing issues reported by beneficiaries. Must be knowledgeable of all federal and state laws regarding the prescribing of controlled substances (i.e. opioids), remaining current on the latest changes, as they occur. Researches outstanding reimbursement checks from the medical claims vendors and contacts the appropriate beneficiary, verbally or in writing, to determine whether the check was received or needs to be cancelled and reissued. Researches the demographic and contact information of beneficiaries for the medical management vendor and Funds' field staff, which involves researching claims history, and contacting the beneficiary, HIPAA-authorized representatives or healthcare providers. Collaborates with Eligibility Services to expedite applications and resolve issues related to the process. Must have a working knowledge of 17 pension plan variations and all processes involved in the determination of pension plan eligibility, health plan eligibility and death benefits. Reviews incoming pension and eligibility documents assuring that all required information has been received for processing. Provides applicants with necessary forms and documents to facilitate processing of applications. Provides necessary information to assist applicant during the application process. Requests necessary information from the applicant to complete the process. Reviews all General/Durable/Medical Power of Attorney, Guardianship, Conservatorship, HIPAA authorization, and other legal representative documents for completeness and applicability to both pension and health benefits. Documents and files documents in FMS and health systems as necessary. Receives and updates beneficiary death records from medical management vendors and field staff. Researches and validates dates of death and requests death certificate, if appropriate. Counsels and assists beneficiaries regarding various special programs and projects, such as the Eligibility questionnaire program, annual 1099-R and 1095 tax form mailings, annual funding notice mailings, and the annual Coordination of Benefits (COB) mailings. Fields and interprets incoming questions concerning robo calls and notices initiated by the UMWA, Medicare, and the federal government. Advises management of new or unusual calls and concerns in order to initiate a Funds'-approved response to these new requests or concerns. Makes outbound calls to collect and tabulate necessary information related to these or other programs and initiatives. 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. Provides phone assistance to In Field Representatives, Field Health Nurses, and Social Workers helping mine workers and beneficiaries directly. Educates and assists beneficiaries concerning Funds' cost-containment and care-management programs by assessing beneficiaries' needs and referring them to our medical management vendor, and by making outbound calls encouraging beneficiaries to attend informative healthcare-related meetings in their communities. Participates in beneficiary outreach meetings to answer questions in person. Identifies beneficiaries with unmet needs, resolves issues within scope of responsibility, and/or refers them to Funds' Case Management Programs, Geriatric Care Management (GCM) Program, community-based programs, or other Funds' professional staff. Maintains a positive relationship with the Funds' community of callers (including the provider community). Identifies appropriate times for call-backs. Maintains and updates personal reference materials for effective performance of duties. Responsible for adhering to all Funds' policies and procedures adopted to comply with the Health Insurance Portability and Accountability Act (HIPAA) governing the privacy, security, and use of protected health information. Travels as required to conduct Funds' business. Assists with special projects and day-to-day activities.

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. TECHNICAL, BUSINESS, and

INDUSTRY KNOWLEDGE

Must be able to pass a test that measures ability to communicate effectively, including oral and written communication skills, and the ability to apply policy and program regulations to specific situations. Demonstrated ability to operate office equipment including personal computers with call management applications, copiers, fax machines, scanner, and printers.

COMMUNICATION SKILLS

Intermediate - Fluency in English and a clear speaking voice required. Ability to speak effectively with managers, Funds' staff, beneficiaries, their representatives, coal company officials, third-party administrators and other interested parties to gather information, provide advice or counsel, or make recommendations regarding procedures or policies. Ability to communicate clearly and effectively under pressure, exercising tact and good judgment. Intermediate - Ability to read and interpret materials such as plan documents, summary plan descriptions, procedures manuals, and processing manuals. Ability to prepare form letters and business correspondence.

MATHEMATICAL SKILLS

Basic - Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent. CERTIFICATES, LICENSES, and/or

REGISTRATIONS

None required.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit for extended periods of time, use of hands to finger, handle, or feel; reach with hands and arms, and talk or hear. Specific vision abilities required by this job include close vision, and the ability to adjust focus. The employee may be required to lift or move up to 10 pounds. Mental demands of this position require the candidate to take a high volume of calls with the ability to handle various personalities. The candidate must be capable of interacting with beneficiaries on the telephone, while performing activities related to call tracking on the computer. The position requires a person with the ability to handle stressful situations with the ability to be diplomatic at all times if bad news must be conveyed.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise levels in the work environment are usually moderate. During periods of travel, noise level may be variable.

PROBATIONARY PERIOD 90

standard workdays pursuant to Sections 5.06, 5.07 and 5.08 of the Collectively Bargained Agreement.

COMPLETE BACKGROUND CHECK REQUIRED.

Job Type:

Full-time Pay:

$42,816.00 - $66,600.00 per year

Benefits:

401(k) 401(k) matching Dental insurance Flexible schedule Health insurance Paid time off Parental leave Professional development assistance Vision insurance

Experience:

Customer service: 2 years (Preferred) Ability to

Commute:

Beckley, WV 25801 (Required)

Work Location:

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