Customer Service Representative 1

Job Description

Under the direction of the Supervisor of Claims Operations and Adjudication, this position is responsible to respond to inquiries from providers and health plan representatives regarding plan benefits, plan policies, claims issues, authorization inquiries and facilitate appropriate resolutions. The Claims Customer Service Representative will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.

1.1 Work directly with providers and health plans to identify and resolve claims processing and service concerns.

1.2 Acts as the provider and member advocate promoting timely complaint and problem resolution for reprocessing Bakersfield Family Medical Group (BFMG) and Coastal Communities Physician Network (CCPN) with every Interaction.

1.3 Responds to time critical questions with detailed and expeditions follow-up to promote accurate and timely processing of issues.

1.4 Employs effective communication methods to promote positive and productive public relations with members, providers, healthplan representatives and other departments.

1.5 Identifies, investigates, resolves and reports member / provider issues to management.

1.6 Promotes high standards of member satisfaction and access to medical care by documenting feedback from Any deviations from established standards are documented in EZ-CAP and reported to management for evaluation.

1.7 Prepares reports and submits results as requested.

1.8 Maintains an effective, efficient, and confidential filing and tracking system to facilitate easy retrieval of contact Information while maintaining confidentiality in accordance with established policy and regulations.

1.9 Identifies members using the 6 key verification HIPAA elements (Name, DOB, Address,

1.10 Phone Number, PCP and preferred language).

1.11 Notify Eligibility when any changes are required on a members file.

1.12 Document all interactions with members, providers, and health plan representatives by appropriately coding and logging in EZ-CAP.

1.13 Answers phones in a specified time frame (30 seconds), while maintaining a high quality of service for members,providers, and health plan representatives.

1.14 Responsible for Member Retention efforts which may include but are not limited to telephone surveys conducted to monitor customer satisfaction.

1.15 Gathers and provides current plan information requested by members ensuring that the information is accurate.

1.16 Assists management staff in completing customer service special projects.

1.17 Must have the ability to verbalize the guidelines.

1.18 Must understand the types of inquiries and concerns that may be received.

1.19 Must understand call handling requirements.

1.20 Must understand Health Plan, Medicare and State of California timelines.

1.21 Must understand members rights to file a complaint.

1.22 Must know how to enter the data into the EZ-CAPdata system.

1.23 Must understand privacy, confidentiality and disclosure laws and protect thisinformation.

1.24 Assist the members in obtaining preventative services.

1.25 Report fraudulent activity.

1.26 Due to your role within the organization, you may be monitored or recorded.

1.27 Perform other duties as assigned by the supervisor.

Requirements

• Highschool Diploma / Certificate required.
• One or more years of experience in a customer service-related field with a high degree of problem solving and decision-making ability.
• Strong telephone and communication skills required.
• Proficient in the use of Microsoft applications (Word, Excel, Outlook).
• Claims and / or billing knowledge is helpful.
• Ability to use correct punctuation, grammar, and spelling.
• Ability to organize and prioritize workload and multi-task.

The pay range for this position at commencement of employment is expected to be between $21.00 and $24.71 However, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience.

If hired, employee will be in an "at-will position" and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department / team performance, and market factors.

Salary : $21 - $25