Description:
- Responds to member and provider inquiries (phone, written, or walk in) regarding all aspects of our client’s business, including claims, in a professional, timely, accurate, and caring manner while consistently meeting all guidelines
Key Duties and Responsibilities:
- Responds to member, provider, and other inquiries via telephone, correspondence or lobby walk-in while meeting all corporate guidelines and performance standards
- Demonstrates appropriate customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness and other skills as identified
- Records, investigates and resolves member complaints as detailed in the Grievance Procedure narrative
- Assists in the education of new members and in the re-education of existing members regarding health plan procedures
- Track grievance case by line of business for compliance and review
- Assist in resolving member and provider complaints
- Makes decisions that are consistent with the concept of a win-win-win for members, associates and our client
- Demonstrates based behaviors such as initiative, accountability and value
- Performs skills necessary to create a high-quality customer experience, as reflected through acceptable quality audit score and productivity
- Performs other duties as assigned
Education:
- A High School or GED (Required)
- An Associate’s Degree in a related field or equivalent work experience
Work Experience:
- 1+ year of experience in a call center or customer service environment (Required)
- 1+ year of experience in grievance experience (Preferred)
- Experience within a health care company (Preferred)
Licenses and Certifications:
- Customer service, quality or training certifications (Preferred)
Skills:
- Demonstrated written communication skills
- Demonstrated interpersonal/verbal communication skills
- Ability to multi-task, good organizational, and time management skills
- Demonstrated organizational skills
- Ability to effectively present information and respond to questions from families, members, and providers
- Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Ability to act on feedback provided by showing ownership of his or her own development
- Demonstrated time management and priority setting skills
- Ability to work as part of a team
- Ability to read, analyzes, and interprets verbal and written instructions
- Seeks to build trust, respect and credibility with all partners through full, honest, consistent, and coordinated communication
Technology:
- Microsoft Outlook
- Knowledge of email systems such as Microsoft Outlook sufficient to communicate with both internal and external contacts
- Microsoft Excel
- Microsoft Word Beginner
- Healthcare Management Systems (Generic)
Level of Supervision Received:
- Under immediate supervision, performs assigned tasks only as instructed, subject to regular check of performance