Service Rep OPL / OPEIU

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Service Rep OPL / OPEIU

Work At Home - New York, Home NY 90001, United States

Full time

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Job DescriptionWorking with UsBenefits & PerksHear From Our TeamHow We Hire

Job Details

Category Claims

Type Full time

Location(s) Work At Home - New York, Home NY 90001, United States

Brand Highmark Inc.

Posted 11/10/2026

Req ID J285901

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Job Description

Company :

Highmark Inc.

Job Description :

Job Summary

Provides quality customer service in a high volume contact center to include providing complete, accurate and timely responses to inquires from subscribers, members, providers, internal and external customers; Processes and adjusts claims.

This is a bargaining unit position. The collective bargaining agreement for this position requires that candidates and employees reside in the following counties in the State of New York: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, or Wyoming.

Duties Note: The following is not intended to be an exhaustive list of all duties required of this position.

ADA

E1. Responds to and resolves inquires from subscribers, members, providers, facilities, groups, other plans and other departments:

• Communicates and interacts with internal and external customers in a clear, unambiguous, concise, professional and empathetic fashion.
• Handles all inquiries and services incoming and outbound calls and correspondence
• Considers all aspects or elements in a logical manner; considers contractual provisions and options to resolve inquiry.
• Utilizes and interprets appropriate reference materials and other necessary resources in responding to inquiries.
• Communicates with internal and external customers via phone, personal contact (lobby walk-ins), email, online chat or in writing; utilizes Letter Reference Guide (LRG) templates as necessary.
• Takes ownership of problems and establishes relationships with customers meeting all corporate guidelines. •Demonstrates an ability to communicate the contractual benefits and requirements to the customer; communicates pros and cons of various plan benefit differences.
• Coordinates with Marketing and Enrollment staff and other internal and external entities, including Medicare and Dept of Treasury, to resolve and respond to timely Medicare Secondary Payor (MSP) Demand Letters.

E2. Pursues, researches, tracks and follows up on information regarding claim benefits, eligibility and all other aspects of business:

• Acts as frontline contact for company, identifies potential problems and inconsistencies and corrects to prevent ongoing or future problems.
• Builds files in COB module and Facets, updates systems to reflect accurate information.
• Identifies, researches and solicits information on possible Reverse Benefits After Termination (RBAT) cases; works with multiple areas to verify RBAT status, creates files and processes/adjusts claims related to positive RBAT cases. •Conducts OPL investigation to include COB claims processing, adjustments, letter generations and building files in both the COB module and Facets. •Addresses, researches and responds to NYS Insurance Department (NYSID) complaints.
• Researches, compiles case information to audit subscribers/ providers for overpayments.
• Identifies potential opportunities, problems and concerns; recommends and forwards to Sr Service Representative and/or Management for review.

E3. Processes and adjusts claims for all lines of business:

• Performs online transactions and/or adjustments utilizing Corporate Claims administration system and ITS standard formats and procedures.
• Determines claim disposition by reviewing correspondence, coordination of benefits (COB) module, and claim inquiry history; follows desk levels, standard operating procedures and COB guidelines.
• Researches, prepares responses and provides supporting documentation. •Identifies potential fraud cases and forwards to Special Investigations Unit.

E4. Researches and compiles information pertaining to all potential subrogation cases and forwards to vendor:

• Assists with compiling data, charting of claims; provides necessary support to resolve cases.
• Assists with intermediary duties between vendor and corporation.

E5. Performs all job duties efficiently, accurately and at an acceptable level of performance.

N6. Performs related clerical duties:

• Files, faxes, copies documents.

E7. Maintains confidentiality and adheres to HIPAA regulations.

E8. Delivers customer service in a professional, polite and efficient manner.

N9. Performs other duties of a similar nature that are not inconsistent with this position or pay grade.

Requirements:

• HS/GED
• One year customer service, contact center, or healthcare related experience as demonstrated by proficiency in one or more of the following areas: claims processing, adjusting or membership processing is required.
• Two (2) years Customer Service related experience in a high volume call/contact center is preferred.

Pay Rate:

$22.81

The starting hourly rate for this position listed above is for new employees. This rate has been established by the Local 153, Office and Professional Employee International Union (OPEIU) collective bargaining agreement (CBA) and is non-negotiable. If the successful candidate is currently a bargaining unit member of the OPEIU, hourly rate is commensurate with their anniversary year and pay grade as per the CBA.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Why Choose Highmark Inc.?

As one of the nation"s leading health insurers, Highmark Inc. relies on a passionate team of over 5,000 people to make healthcare higher-quality, accessible, and affordable. We are known for how deeply we care-about our members and our employees. If you are looking to build a career with real purpose, you belong at Highmark.

Benefits & Perks

Taking Care of You

Your Benefits at a Glance

• Health: Complete medical, dental, vision, prescription, HSA, and FSA coverage.
• Time Off: Paid vacation, holidays, and dedicated volunteer time.
• Finance: Employer-sponsored 401(k), life/disability insurance, and tuition reimbursement.
• Perks: Exclusive team discounts on shopping, memberships, and events.

Medical Coverage

Medical, prescription drug, dental, and vision coverage

Paid Time Off

Vacation, holidays, volunteering

Retirement Package

Employer-sponsored 401(k) plan

Insurance & Coverage

Life, AD&D and disability insurance

Onsite & Preventative Care

We make staying healthy easy with 100% covered preventative exams (including flu shots) and onsite pharmacy services at major campuses. Plus, stay active with free fitness center access at major Highmark campuses, Allegheny General, and West Penn Hospital.

Make Mindful Changes

Secure bicycle parking at major campuses. Healthy food options at onsite cafeterias. Stress management classes including yoga, mindfulness, and meditation.

Holistic Support, 24/7

Work-life resources including assistance programs and financial counseling services. 24/7 telephone access to health and wellness coaching.

Get Rewarded for Giving Back

Health incentive program that rewards team members. Team member networks to gather in the name of health. Paid volunteer time and incentives for making a difference.

Hear from Our Team

Real people, real stories

"I have met some really great people over the years at Highmark Health and the company has treated me really well. I get really good benefits. I"ve always been rewarded for working hard. That"s what keeps me here."

Victoria T.

Associate Strategy Analyst, enGen

"I love participating with the PRIDE BRG. It"s an engaged, dynamic group of almost 400 people. I also love to turn on the digital hub on my computer and see what"s going on with any of the Business Resource Groups. It"s really neat to be able to support other BRGs and see others support PRIDE. Every time I go to a different BRG event, I always feel welcome, even if I"m not part of that group."

Amanda M.

Director of Social Determinants of Health | Vice Chair of PRIDE

Our Hiring Process: Step-by-Step

1. Apply

Find a role that sparks your passion and submit your application! We'll send an immediate confirmation email, and our team will review your qualifications over the next 1-2 weeks.

2. Interview

If your profile is a great match, we'll reach out to schedule your interview-whether by phone, video, or in person. Don"t worry, we'll provide all the prep details in advance so you can shine.

3. Job Offer

The moment you've been waiting for! If selected, we'll connect to celebrate and walk you through the details: compensation, benefits, paid time off, and all the perks of joining the team.

4. Pre-Employment

After you accept online, we'll guide you through standard screening (including a background check and drug screen, plus health screenings for certain clinical roles). Once cleared, we"ll officially confirm your start date!

5. Onboarding

Welcome aboard! Before Day 1, we'll send everything you need to hit the ground running-including your schedule, location, and the required identification documents to bring with you.

Bonus Fast-Track Tip

Applying for EVS, Dietary, or Customer Service roles? You can skip the traditional line and chat with Bridget, our AI recruiting assistant, to find open roles and schedule an eligible interview instantly.

Apply Now

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Highmark Health is an independent licensee of the Blue Cross Blue Shield Association.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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