In-Field Representative

SUMMARY

The purpose of this position is to provide services directly to beneficiaries and families to address their health and pension needs. Promotes Funds' programs and coordinates service delivery with other identified or sponsored health, community and social services. Builds and maintains positive relationships with health-care providers who care for Funds' beneficiaries and resolves beneficiary and provider disputes over claims payments or reimbursement amounts. Is the primary contact for community-based resources. Establishes and maintains working relationships with UMWA Representatives, including scheduled hours in local district offices. Develops and implements wellness programs and other activities in the field. Works as part of a multi-disciplinary health professional team to address the health-related needs of beneficiaries. Educates and informs applicants both in person and telephonically with excellent communication skills and subject matter expertise on Funds' pension and / or health benefits.

Essential Duties and Responsibilities include the following :

Is the liaison for the Funds with the UMWA officials providing assistance in resolving Funds' related eligibility and claims issues. Works with UMWA officials to promote Funds' initiatives. Maintains regularly scheduled office hours in UMWA District offices.

Applies knowledge of complex benefit plans while counseling applicants in person and telephonically. Responds to eligibility questions from applicants, beneficiaries, union representatives, and others.

Responds verbally and / or in writing to health-care providers, applicants, beneficiaries, union representatives, coal company representatives, government agencies or other interested parties regarding the nature and scope of the benefit plans and programs available, and the rules, regulations, policies and procedures governing those plans.

Coordinates with Eligibility Services and local UMWA District offices on organizing and attending mine closings and other outreach events.

Collaborates with Eligibility Services to advance the progress of applications and to resolve issues related to the process.

Participates in the Medicare Audit, collaborating with clinical reviewers, consultants, and health-care providers to obtain medical records, follow-up documentation, and record notes.

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.

Builds and maintains positive relationships with health-care providers who care for Funds beneficiaries.

Provides a local presence for Funds' sponsored programs and services. Participates in community projects and activities developing effective working relationships with providers, community agencies, and public service representatives.

Maintains positive provider relations and assists with recruitment, obtaining contracts, and training providers on Funds' electronic claims submissions.

Counsels applicants, beneficiaries, Funds' providers, and other interested parties with respect to Funds' benefits, programs, rules, regulations, policies, and procedures.

Advocates for beneficiaries and mine workers in resolving issues relevant to other agencies such as Medicare, Medicaid, and Black Lung.

Researches and resolves claim-related inquiries from beneficiaries, providers and union officials. This includes contacting providers and health insurance carriers in order to resolve the inquiries and consulting with the Funds' call center if needed.

Identifies provider relations issues that may impact beneficiaries and refers them to the Provider Representative, working closely with Provider Relations' staff to maintain a continuum of care for beneficiaries.

Reports claim issues, such as fraud and abuse and other provider issues reported by beneficiaries to the Director, Operations and Eligibility Services; the Director, Network Development and Provider Relations; or the Regional Director.

Develops and implements strategies to visit beneficiaries in their homes to collect and document beneficiary health information utilizing designated assessments. Provides and promotes health education programs and assists beneficiaries and caregivers with benefits and programs. Enables face-to-face personal relationships and establishes rapport with beneficiaries and caregivers. Identifies beneficiaries with unmet needs and makes appropriate referrals to other health professionals and community resources. Recruits beneficiaries to participate in ongoing health education, wellness and care coordination programs.

Travels as required to conduct Funds' business.

Other duties as assigned. Performs duties that support the day-to-day activities of the office.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Must be a self-starter with the ability to work without day-to-day supervision. Must be able to manage multiple priorities and handle competing demands in an effective manner.

Education and / or Experience

• Bachelor's degree from an accredited college or university or a comparable degreed program in Political Science, Social Services, Humanities, Health Sciences, Language Arts, Communications / Journalism, Public or Business Administration and / or Labor Relations PLUS two years' experience in a position for which the primary responsibility was the development, implementation and / or conduct of health-care programs or provider relations, and experience resolving problematic medical claims and benefits disputes between health-care providers and payers. OR
• High school or General Education Degree (GED) PLUS three or more years of health-care experience in a position for which the primary responsibility was the development, implementation and / or conduct of health-care programs or provider relations, and experience resolving problematic medical claims and benefits disputes between health-care providers and payers.

Communication Skills

Intermediate – Requires proficient oral communication skills to effectively work with beneficiaries, UMWA officials, Field Office staff, physicians, hospitals and community agencies. Also requires excellent writing skills to compose beneficiary communications, business letters and routine program reports. Maintains a positive attitude to enhance effective working relationships and to serve as a positive representative of the organization.

Intermediate – Ability to read and interpret materials such as plan documents, summary plan descriptions, procedures and processing manuals.

Technical, Business, and Industry Knowledge

Must be able to pass a test that measures the ability to communicate effectively, including oral and written communication skills, and the ability to apply complex regulations to specific situations.

Must have knowledge of Medicare, Parts A and B, state and federal regulations impacting health-care, medical terminology, cost management concepts, compilation and analysis of statistical data, other health insurance carriers' policies and procedures, health-care management issues and terminology, and knowledge of appropriate services to elderly beneficiaries who may be frail or disabled.

Must have basic knowledge of pension regulations, medical claims, and pharmacy adjudication.

Must have prior experience in customer service or benefits counseling activities.

Mathematical Skills

Basic Requires use of mathematical formulas and calculations for report analysis and preparation.

Reasoning Ability

Ability to identify health-care issues among the Funds' population, establish facts, and draw valid conclusions.

Certificate, Licenses and Registrations

Maintains current certification on Basic First Aid and CPR.

Maintains Notary Public Certification / License and provides Notary Public service to beneficiaries as appropriate.

Other Skills and Abilities

Requires computer skills at an intermediate level. Ability to use word processing, spreadsheet software and other software programs. Requires exceptional time management skills.

Physical Demands

The physical demands described here are representative of those that are typically experienced 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 and talk or hear, walk, climb stairs and drive an automobile. May occasionally be required to lift and move objects weighing up to 20 lbs.

PROBATIONARY PERIOD

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

COMPLETE BACKGROUND CHECK REQUIRED.