[Hiring] Customer Care Representative @Sharp HealthCare

Role Description

Responsible for direct and timely communication between the Plan and Plan members, potential members, providers, employer groups, brokers, internal departments, and external agencies. Maintains high level of knowledge regarding Plan products, premiums, benefits, and procedures. Uses knowledge and judgment to select appropriate resources for assisting callers. Provides information on all aspects of Plan products, premiums, benefits, policies, and procedures. Responsible for accurate problem-solving. Researches and resolves concerns.

Qualifications

• H.S. Diploma or Equivalent
• Less Than 1 Year Minimum of six (6) months experience as a Customer Call Center Representative.

Preferred Qualifications

• Associate's Degree in Business administration or health care administration (including courses of study in accounting, finance, marketing, and health care administration)
• 2 Years Customer service or medical office experience.
• 1 Year Experience working full time as SHP Customer Care Temporary CCR I.

Other Qualification Requirements

• Medical office certification, to include medical terminology, preferred.

Essential Functions

• Access patient data
• Documents all calls in the IDX Customer Service Module immediately.
• Verifies prescription drug eligibility, benefits, claims, and authorizations in PBM's MedAccess system.
• Adds and updates member information in the MedAccess system.
• Maintains current knowledge of IDX system modules for Registration, Enrollment, Claims, Utilization Management, and Premium Billing.
• Verifies enrollment, benefits premiums, and other individual and group information in Salesforce.
• Generates member letters using Globalworks.
• Retrieves member documents stored in OnBase.
• Uses SharpConnect to assist members with online inquiries.

Customer Service

• Ability to understand and resolve common Commercial member inquiries/complaints by phone.
• Provides prompt, accurate, and excellent services to internal and external customers.
• Develops solid professional working relationships with various internal departments and units and, as required, vendors, providers, employers, brokers, and/or other customers.
• Works collaboratively with other Plan and medical group departments to address customer questions and concerns, including Health Services, Enrollment, Claims Research, Underwriting.
• Works collaboratively with health care providers and office staff to facilitate access to care.
• Maintains a complex and evolving knowledge of health insurance and health care reform mandates.

General Support

• Participates in special projects and other duties as assigned.
• These may include, but are not limited to, work groups, proposals, audits, and back-up support for other departments.

Member Support

• Assists new and existing members in attaining a workable understanding of their health coverage, clarifies terminology in enrollment materials, and instructs members regarding how to utilize the services of the Plan and the provider network.
• Answers inquiries from potential members, members, brokers, employer groups, State and County representatives, Plan providers, internal departments, and all other callers, including:
• Verification of eligibility, enrollment, and PCP assignment;
• Benefit, co-payment, and referral questions;
• Requests for PCP changes, address changes, ID cards, benefit materials;
• Inquiries regarding premium and subsidy amounts and balances;
• Clarification of conversion, COBRA, and Cal-COBRA enrollment procedures, including quotes of approximate rates.
• Documents member concerns, complaints, and appeals, and forwards to the appropriate Customer Care Lead or Supervisor on a daily basis.
• If unable to provide immediate assistance, promptly returns calls with answers and resolutions.
• Utilizes appropriate handbooks, Evidence of Coverage, supplemental benefit information, and other reference material as needed to quote Plan benefits, exclusions, and policies.
• Maintains detailed knowledge of required materials and resources, including:
• Operations policies and procedures
• All Combined Evidence of Coverage (Member Handbooks) and Employer Group Benefit Agreements
• Language Line.
• Informs and works collaboratively with other Plan departments, in areas including but not limited to:
• Forwarding prospects for new brokers or employer groups to Marketing;
• Working with Health Services regarding authorization requests and assistance for special need cases;
• Forwarding potential provider education issues to Provider Relations;
• Documenting potential member fraud, COB, and third-party liability issues, and reporting to the appropriate department;
• Documenting requests for additions to the provider network and forwarding to Contracting.
• Assists members with premium and billing questions. Processes ACH and credit card payments over the phone.
• Uses appropriate resources to describe and recommend plan options to individuals interested in purchasing Sharp Health Plan coverage.

Problem Resolution

• Identifies and recommends solutions for operational problems to ensure continued high-quality service to internal and external customers.
• Maintains an organized work area.
• Effectively utilizes a wide range of reference materials.
• Demonstrates knowledge of specific enrollment, benefit, and premium information for commercial (group and individual) and Medicare products.
• Complies with regulatory and accreditation requirements and timelines for customer service including DMHC, CMS, and NCQA.

Projects

• Works with moderate supervision on projects assigned by Customer Care Supervisor, including but not limited to:
• New member orientation;
• Premium billing reminders and payment processing;
• Member education;
• Member claims investigation and resolution;
• Pharmacy prior authorizations and eligibility;
• Member appeal/concern investigation and documentation;
• Member reimbursement requests.

Department Policies and Procedures

• Maintain overall scorecard score of 3.0 or higher for 6 consecutive months.
• Meet or exceed in all scorecard metrics for 6 consecutive months.
• Behavior Standards - Average Score of 8 or higher within a 12 months period.
• Attendance - No more than 2 unscheduled occurrences within a 12 months period.
• Knowledge - Customer Care Commercial Knowledge Assessment score of 80% or above.

Knowledge, Skills, and Abilities

• Ability to effectively participate in the activities of the Customer Care area.
• Mature and sound judgment in the commitment of the plan's mission and operating goals.
• Superior interpersonal skills.
• Knowledge of current matters relating to health maintenance organizations, performance management, and customer satisfaction assessment and delivery.
• Basic computer and writing skills.
• Demonstrated knowledge of Plan benefits, policies, and procedures.
• Bilingual preferred but not required.