Overview:
Under the direct supervision of the Customer Support Center Supervisor, the Customer Support Representative I (CSR) is the front-line support to members, member advocates and providers. The CSR I provide superior customer service to all incoming callers while assisting with their inquiries and requests. Calls include but are not limited to eligibility verification, authorizations status, PCP changes, appeals and grievances, claims status and requests for EOBs. CSRs I are expected resolve and/or escalate inquiries/requests and document each call interaction in a clear, concise, professional, and timely manner.
Responsibilities:$ads={1}
- Provide superior customer service to all incoming callers to ensure an exceptional customer experience.
- Receive and respond to incoming calls from members, member advocates, providers, health plan representatives, etc. Identify and resolve issues related to patient care and services.
- Provide assistance with inquiries such as eligibility, authorizations status, claims status PCP changes, appeals and grievance intake, and various other inquiries.
- Responsible for research, resolution, or escalation of provider inquiries regarding eligibility, claims status, check tracer, EOB requests and payment disputes.
- Conduct provider education related to claims.
- Interface with other departments regarding questions about provider configuration or other relevant provider issues.
- Handle of complex claims inquiries.
- Use DOFR, benefit schedules, and other resources to identify issues with claims payments.
- Assist callers in connecting with other internal departments or external parties such as partner PCP offices, health plans, pharmacies, etc.,
- Educate callers on the use of the member and provider web portal.
- Properly identify member’s health plan assignment for appropriate re-directing when necessary.
- Collect, verify, and update member demographic information information systems.
- Make outbound calls for follow up purposes when needed. Set reasonable follow up expectations with callers and meet or exceed those commitments.
- Continuously work on open inquiry log and maintain minimal open cases.
- Use appropriate subject codes, accurately, thoroughly, and clearly document all inquiries in tracking systems.
- Recognize and alert management of inappropriate trends during customer calls. Provide process improvement recommendations.
- Adhere to individual and departmental key performance indicators (KPIs) such as number of inbound calls per day, wrap up time, handle time, QA audit performance, abandonment rate, and service level.
- Assist with training of new and existing staff when called upon.
- Actively participate in all departmental meetings, training sessions, and other activities.
- Maintain confidentiality of all protected health information in accordance with corporate guidelines.
- Perform other duties as assigned.
- High School Diploma or GED required. Associates or bachelor’s degree preferred.
- Minimum of 2 years of ACD call center experience
- Minimum of 1 year in medical or healthcare environment preferred.
- Bilingual in Spanish required.
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