ESSENTIAL FUNCTIONS

Responsible for inbound phone inquiries primarily dealing with either:

• Member benefits and eligibility related to the Medicaid, CHP and FHP product lines or


• Provider benefits, eligibility, PEP and claim status, member pharmacy calls, utilizing prior approval skills (ACP/DME and CCD) and placing outbound calls on a routine basis.


• Resolve issues with respect to benefits and eligibility by researching documentation, system information or gaining knowledge from other employees, management or departments.

• Interact with customers, document call specifics and demonstrate quality program behaviors to create an outstanding relationship with each caller.


• Work with outside vendors as needed to answer questions or resolve issues.


• Respond to member correspondence/email in writing utilizing an existing Customer Service system letter to effectively respond to members.


• Conduct orientation to new members by providing an overview of the members plan and pertaining administrative policy.

SECONDARY RESPONSIBILITIES

• Demonstrate awareness, motivation, and technical skills to assist in the development and growth of the customer service teams and help to identify process improvements.


• Assist in department/company projects, as needed, i.e. provide feedback about the customers experience.

EDUCATION and EXPERIENCE

• High School Diploma, GED, or Equivalent work experience


• Must be computer literate and able to multi-task i.e. document call experience while using the Quality Program.


• Excellent communication and interpersonal skills.


• Bilingual fluency in English and Spanish

Preferred Qualifications:

• Healthcare/Insurance environment (familiarity with medical terminology, health plan documents, or benefit plan design)


• Social work, behavioral health, disease prevention, health promotion and behavior change (working with vulnerable populations)


• Sales or account management experience


• Customer Service Experience

Domain Skills

* Proficiency Legends