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Primary Responsibilities:

• Answer incoming phone calls from customers and identify the type of assistance the customer needs (i.e. benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits (EOBs)
• Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems
• Own problem through to resolution on behalf of the customer in real time or through comprehensive and timely follow-up with the member
• Review and research incoming healthcare claims from members and providers (doctors, clinics, etc) by navigating multiple computer systems and platforms and verifies the data/information necessary for processing (e.g. pricing, prior authorizations, applicable benefits)
• Ensure that the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan
• documents/certificates)
• Communicate and collaborate with members and providers to resolve issues, using clear, simple language to ensure understanding
• Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendance

Required Qualifications:

• High school diploma / GED (or higher) OR 10+ years of equivalent working experience
• All new hires will be required to successfully complete the Customer Service training classes and demonstrate proficiency of the material

Soft Skills:

• Demonstrated 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)
• Demonstrated ability to listen skillfully, collect relevant information, determine immediate requests and identify the current and future needs of the member
• Proficient problem-solving approach to quickly assess current state and formulate recommendations
• Proficient in translating healthcare-related jargon and complex processes into simple, step-by-step instructions customers can understand and act upon
• Flexibility to customize approach to meet all types of member communication styles and personalities.