Job Description

JOB SUMMARY:
Responsible for accurately and completely answering and documenting inquiries from members, employers, employer groups and providers. Facilitates communication between self, other departments, members, providers, provider offices, employers, and brokers to ensure that needs of members are met.

EDUCATIONAL REQUIREMENTS
None specified

CERTIFICATION & LICENSURE REQUIREMENTS
Medical Terminology within one (1) year of hire

EXPERIENCE REQUIREMENTS
Three (3) General - Customer Service. Must be proficient in using a computer keyboard, navigating multiple software applications, managing a multi-line phone and completing documentation during the course of a call.

SKILLS AND KNOWLEDGE
Must be able to project a professional, pleasant image, while interacting with a variety of personalities and cultures. Must demonstrate tact and diplomacy in interpersonal interactions, in addition to maintaining composure in confrontational situations.


ESSENTIAL FUNCTIONS:

• Meets standards for documentation, answering and follow-up on all benefit, eligibility, network, and claims inquiries from Health Alliance members and providers generated by telephone, walk-in, or written correspondence.
• Takes action to resolve customer service, claims, or billing complaints by partnering with other departments if and when necessary. Follows up to ensure that appropriate changes were made to resolve the source of the problem. Refers unresolved complaints to the Customer Service Complaint Resolution Specialist or advises members/providers of the right to appeal.
• Educates members and providers regarding a variety of insurance topics, including, but not limited to Healthcare Reform, Exchanges, coordination of benefits and Medicare coordination.
• Processes requests for member materials including, but not limited to ID Cards, federally required Summaries of Benefits and Coverage, Policies, Schedules of Benefits, Provider Directories, Explanations of Benefits, and Remittance Advices.
• Assists members in accessing company websites.
• Consistently meets or exceeds department specific performance and quality requirements.
• Basic communication skills (Telephone Courtesy Guidelines P&P, scripting, and scores/feedback from Quality Assurance Advisor and Customer Service Lead).
• Basic computer skills (all applications used by Customer Service).
• Basic problem solving skills.
• Follows and adheres to accountability structure and required behavioral standards.

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