HP Customer Serv Rep Non Bil

GENERAL PURPOSE OF JOB: The 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 o Behavioral Health
• Claims o 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
• Customer service experience
• Experience working in a call center or healthcare related field is a plus
• 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