Customer Service Representative 2
Heritage Provider Network, Bakersfield, CA, United States
Level II Customer Service Representative
Under the direction of the Director of UM and CS, this position is responsible to respond to inquiries from members, providers and health plan representatives regarding plan benefits, plan policies, claims issues, authorization inquires, and facilitate appropriate resolutions. The representative will have daily and extensive contact with customers to resolve complex issues, interpret policies/procedures, benefits, respond to requests for service, survey members and solve problems. The Level II 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. Answer inquiries related to member plan benefits, network providers, and account related questions. 2. Work directly with members, service providers and health plans to identify and resolve health care service concerns. 3. Embrace ongoing personal development through regular training which helps to enhance one's own technical problem-solving skills. 4. Respond to questions with detailed and expeditious follow-up to promote accurate and timely processing of issues. 5. Employ effective communication methods to promote positive and productive public relations with members, providers, health plan representatives and other departments. 6. Identify, investigate, resolve, and report member and provider issues to appropriate department and/or management when necessary. 7. Promote high standards of member satisfaction and access to medical care by documenting feedback from members. 8. Maintain detailed documentation of all interactions with members, providers and health plan representatives by appropriately coding and logging in systems utilized while maintaining confidentiality in accordance with established policies and regulations. 9. Identify members using at least 4 key verification HIPAA elements (name, date of birth, address, phone number, primary care physician and/or member ID). 10. Communicate with corresponding departments in regard to any changes to a member's file and/or health record. 11. Adhere to all call metrics as set forth by HPN. 12. Verify eligibility by researching and providing current plan information requested by members and providers ensuring that the information is accurate. 13. Proficient in navigating through multiple computer applications, effectively researching and identifying solutions using computer-based resources with speed and accuracy. 14. The ability to relate to customers in a professional and courteous manner. 15. Exhibit excellent attention to detail and ability to multi-task. 16. Demonstrate empathy, patience, adaptability, and strong positive work ethic. 17. Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems. 18. Communicate and collaborate with members and providers to resolve issues, using clear, simple language to ensure understanding. 19. Exhibit the ability to translate healthcare-related jargon and complex processes into simple, step-by-step instructions a member or provider can understand and act upon. 20. Assist management staff in completing customer services related special projects. 21. Responsible for member retention efforts which may include but are not limited to telephone surveys conducted to monitor customer satisfaction. 22. Maintain flexibility to customize approach to meet all types of member communication styles and personalities. 23. Illustrate proficient conflict management skills to include ability to resolve issues in a stressful situation and demonstrating personal resilience. 24. Demonstrate ability to listen skillfully, collect relevant information, determine immediate requests and identify the current and future needs of the member. 25. Provide responsive, timely, telephone, email, fax and chat support. 26. Handle all walk-in members and family representatives of the members, which include complaints and inquiries. 27. Provides training to Level I CS Reps as necessary and indicated by management. 28. Handle complex issues, takes possession of escalated calls from Level I CS Reps. 29. When necessary or as requested, will include and/or assist CS Management on complex issues. 30. Demonstrate ability to quickly build rapport and respond to customers in a compassionate manner by identifying and exceeding customer expectations (responding in respectful, timely manner, consistently meeting commitments). 31. Due to role within organization you may be monitored or recorded. 32. Complete HPN compliance training annually. 33. Complete Language and Cultural Linguistics training annually. 34. Perform other job-related duties as required.
Under the direction of the Director of UM and CS, this position is responsible to respond to inquiries from members, providers and health plan representatives regarding plan benefits, plan policies, claims issues, authorization inquires, and facilitate appropriate resolutions. The representative will have daily and extensive contact with customers to resolve complex issues, interpret policies/procedures, benefits, respond to requests for service, survey members and solve problems. The Level II 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. Answer inquiries related to member plan benefits, network providers, and account related questions. 2. Work directly with members, service providers and health plans to identify and resolve health care service concerns. 3. Embrace ongoing personal development through regular training which helps to enhance one's own technical problem-solving skills. 4. Respond to questions with detailed and expeditious follow-up to promote accurate and timely processing of issues. 5. Employ effective communication methods to promote positive and productive public relations with members, providers, health plan representatives and other departments. 6. Identify, investigate, resolve, and report member and provider issues to appropriate department and/or management when necessary. 7. Promote high standards of member satisfaction and access to medical care by documenting feedback from members. 8. Maintain detailed documentation of all interactions with members, providers and health plan representatives by appropriately coding and logging in systems utilized while maintaining confidentiality in accordance with established policies and regulations. 9. Identify members using at least 4 key verification HIPAA elements (name, date of birth, address, phone number, primary care physician and/or member ID). 10. Communicate with corresponding departments in regard to any changes to a member's file and/or health record. 11. Adhere to all call metrics as set forth by HPN. 12. Verify eligibility by researching and providing current plan information requested by members and providers ensuring that the information is accurate. 13. Proficient in navigating through multiple computer applications, effectively researching and identifying solutions using computer-based resources with speed and accuracy. 14. The ability to relate to customers in a professional and courteous manner. 15. Exhibit excellent attention to detail and ability to multi-task. 16. Demonstrate empathy, patience, adaptability, and strong positive work ethic. 17. Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems. 18. Communicate and collaborate with members and providers to resolve issues, using clear, simple language to ensure understanding. 19. Exhibit the ability to translate healthcare-related jargon and complex processes into simple, step-by-step instructions a member or provider can understand and act upon. 20. Assist management staff in completing customer services related special projects. 21. Responsible for member retention efforts which may include but are not limited to telephone surveys conducted to monitor customer satisfaction. 22. Maintain flexibility to customize approach to meet all types of member communication styles and personalities. 23. Illustrate proficient conflict management skills to include ability to resolve issues in a stressful situation and demonstrating personal resilience. 24. Demonstrate ability to listen skillfully, collect relevant information, determine immediate requests and identify the current and future needs of the member. 25. Provide responsive, timely, telephone, email, fax and chat support. 26. Handle all walk-in members and family representatives of the members, which include complaints and inquiries. 27. Provides training to Level I CS Reps as necessary and indicated by management. 28. Handle complex issues, takes possession of escalated calls from Level I CS Reps. 29. When necessary or as requested, will include and/or assist CS Management on complex issues. 30. Demonstrate ability to quickly build rapport and respond to customers in a compassionate manner by identifying and exceeding customer expectations (responding in respectful, timely manner, consistently meeting commitments). 31. Due to role within organization you may be monitored or recorded. 32. Complete HPN compliance training annually. 33. Complete Language and Cultural Linguistics training annually. 34. Perform other job-related duties as required.