What are the responsibilities and job description for the Customer Service Representative, Member Services - Intermediate position at Blue Shield of California?
Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to diversity, equity, and inclusion combines a focus on our people, processes, and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.
Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in – join us!
Your Role
Start Dates: May - July 2022
As a Customer Service Representative (CSR) you are in charge of upholding our mission of providing service worthy of our family and friends. You are empowered to provide members with peace of mind that their current issue is resolved and that none are on the horizon.
Successful CSRs deliver an effortless customer experience by:
- Taking the lead – our CSRs take ownership of members’ issues, relieving members’ stress while guiding them to a quick and easy resolution.
- Identifying future problems – not only do our CSRs solve the current member concern but they actively identify and solve any lurking complications the member may encounter after their first interaction.
- Sharing insights with peers and management – our positive team culture relies on open communication to continuously improve how our work gets done.
- Having fun! – our work is important, but we don’t take ourselves too seriously. We love helping others and have a fun community dedicated to doing so!
Your Work
Responsibilities include:
- Resolve incoming calls concerning members eligibility, benefits, provider information, monthly premium billing, clinical and pharmacy needs
- Compose routine and non-routine correspondence to answer benefits/provider inquiries in writing
- Coordinate membership changes such as member's primary care physician
- Perform inventory reduction, routine to mid-level, (i.e. member inquiries, may initiate claim adjustments, responds to emails, etc.)
- Review and analyze member claims for accuracy as well as member education on how benefits are applied
- Participate in quality and efficiency workgroups to continuously improve quality member/customer satisfaction as requested
- Proactively analyze available programs, determine program eligibility and connect member to appropriate BSC vendors, Health Advocates, Social Workers, Pharmacy Techs, and Pharmacists. Verify the member is included in or targeted for any outreach or care gap programs and connect members to programs or services when appropriate. Engage members with their wellness plan options
- Comprehensive resolution of pharmacy calls concerning benefit coverage, co-pays, formulary coverage, vacation overrides, and utilization management requirements
- Provide prescription related benefit coverage (e.g. explanation of coverage or benefit summary related): Provide prescription co-pays. Provide prescription formulary coverage information and utilization management requirements using web posted printed formulary. Provide a brief description of coverage denial reason and alternatives as listed in the printed formulary. Perform prescription claim overrides
- Provide deductible and max out of pocket information
- Provide status of a prior authorization requests
- Assist members may when and how to appeal a coverage decision
- Training provided
- Other duties as assigned
Your Knowledge and Experience
- Requires a high school diploma or GED
- Requires at least 3 years of prior relevant experience
- Requires basic job knowledge of Microsoft Suite systems and the ability to proficiently use applications on a computer
Our Values
- Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short
- Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes
- Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals
