SUMMARY OF DUTIES:

Communicates with a diverse customer (member/provider/health plans) base, regarding individual questions and concerns specific to plan benefits, coverage determinations, event information, claims status and complaints, conducts inquiries and research related to questions and concerns. Coordinates with others within and outside the organization to facilitate timely resolution of member, provider and health plan issues. 

MAJOR DUTIES:

• Takes inbound calls and responds appropriately to all customer questions and/or concerns.
• Provides information as requested by caller related to eligibility, claims, providers, vendors, or other processes, including grievances and complaints.
• Provides information as requested related to coverage determinations and appeals processes.
• Maintains applicable records and files regarding customer communications and service coordination.
• Reviews all documents received for completeness, verifies eligibility of both the member and provider/vendor, and if applicable contract status.
• Verifies claims status and coordinates information, as applicable, with provider and claims staff.
• Forwards calls as required to appropriate supervisor or clinical staff for further response or follow up.
• Ensures confidentiality of all hard copy, electronic, and verbal communication, and adheres to organization’s policies related to privacy and disclosure.
• Promotes a positive image of the organization and the department in all aspects of communication and contact.
• Performs other related duties as required

PERFORMANCE STANDARDS

• Receives inbound calls from members, providers and others and facilitates response and closure.
• Makes outbound calls to coordinate information, service and communications.
• Takes appropriate and timely action regarding problem resolution.
• Uses translation and language services appropriately and timely.
• Refers member or provider calls that require clinical assistance to appropriate clinical staff.
• Maintains applicable files and documentation in an organized manner.

KNOWLEDGE/SKILLS:

• High School Diploma or equivalent
• Knowledge of medical terminology a plus.
• Ability to communicate effectively with co-workers, physicians, provider offices, and members a must.
• Ability to work under pressure a must.
• Ability to work independently a must.
• Problem solving skills and ability to set priorities essential
• Word processing/computer data entry experience with ability to type at least 45 wpm with good accuracy, and accurate and speedy ten key skills.
• Bi-lingual in English/Spanish preferred.

EXPERIENCE:

• Previous experience in customer services or related function in health care organization preferred.
• Experience in a managed care environment preferred.