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GENERAL PURPOSE OF JOB:

The Bilingual Call Center Customer Service Representative is responsible for the assisting Member/ Provider with healthcare inquires concerns, or complaints via telephone.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

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, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or health plan administration, as required.

General Duties:

Assist members and providers by responding to telephone inquiries in a prompt, accurate and objective manner regarding but not limited to: Abuse, Neglect and Exploitation, Authorizations, Behavioral Health, Claims, Complaints, Crisis Calls, Eligibility, Health Insurance Benefits, Locating providers, Pharmacy Benefits, Transportation, Waste Abuse, and Fraud.

• 90% of the scheduled time on the phone according to business needs.

• Drives resolution of caller questions/issues on the first call whenever possible and ensures proper documentation of calls and resolution actions.

• Understand and adhere to HIPAA requirements.

• Adhere to Regulatory Guidelines and policies & procedures.

• Navigating through complex computer systems to identify the status of the issue and provide appropriate response to caller.

• Review previous call interactions/notes.

• Communicate monthly messages to members and providers on a specific need basis.

• Deal tactfully and empathetically with members and providers.

• Establish and maintain effective working relationships with provider office staff.

• Read, comprehend, and verbalize processes and procedures of the organization and of health insurance coverage.

• Multi-task by utilizing multiple complex computer applications.

• Pay close attention to detail.

• Identify issues/trends and escalate to Supervisor / Manager when assistance is needed.

• Develop relationships with other departments to provide feedback about root cause issues.

• Intervene with providers on behalf of the customer to assist with appointment scheduling or connections with specialists for assistance when needed.

• Assist customers in navigating through the Driscoll Health Plan website and encourage and reassure them to become self-sufficient.

• Own problem through to resolution on behalf of the customer in real time or through comprehensive and timely follow-up with the member and or provider.

• Research complex issues across multiple databases and work with internal departments to resolve customer issues and/or partner with others to resolve escalated issues.

• Other duties as assigned.

EDUCATION AND/OR EXPERIENCE:

• Minimum of a high school diploma or equivalent

• 6 months of experience working in a call center or healthcare-related field

• Strong customer service skills, including courteous telephone etiquette and professionalism

• Prior understanding and awareness of call center metrics and goals preferred

• Prior healthcare experience, in particular, Medicaid Insurance Plans preferred

• Ability to type a minimum of 35 words per minute

• Knowledge of managed care processes and health insurance coverage preferred • Knowledge of medical terminology preferred

• Outstanding communication skills and the ability to understand complex situations to effectively handle escalated customer needs

• Analytical skills and the ability to read and interpret data

• Problem solving abilities

• Ability to work independently and as a part of a team

• Ability to operate computer programs – Proficiency with Microsoft Office applications, particularly Outlook, Word and MS Teams

ENGLISH LANGUAGE SKILLS:

• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.

• Ability to speak English and Spanish required.