Responsible for communicating with physicians and patients regarding plan benefits and eligibility. This position emphasizes member education, customer service and front-line problem solving.
Essential Duties and Responsibilities:
Thoroughly understands the managed care philosophy and the company's products.
Receives and responds to member and provider phone calls/inquiries, questions and concerns in all areas including enrollment, claims, benefit interpretation, and referrals/authorizations for medical care.
Receives, records, and resolves member complaints and problems.
Answers calls in a pleasant and courteous manner within 30 seconds.
Routinely accesses member information via multiple computer systems.
Accurately documents member and provider contacts on the computer system.
Responsible for ensuring that members receive accurate and complete information.
Communicates effectively and professionally with members, providers, and state agencies.
Screens telephone calls and directs to the appropriate area or person as necessary.
Acts as a liaison between members, physicians, and health plan.
Researches member concerns and attempts to resolve issue during call.
Works in coordination with other departments concerning member and provider issues.
Prepares documentation and reports for review by the Customer Services Director and Supervisor.
Maintains confidentiality per HIPAA guidelines.
This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.
Skills and Abilities:
Verbal and written communication skills.
Ability to work independently.
Ability to meet deadlines.
Ability to maintain a good rapport and cooperative working relationship with team.
Work Schedule:
As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week. *****The company reserves the right to change the work schedules based on the company needs.
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move up to 15 pounds.
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.
We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.
Qualifications
High school diploma or general education degree (GED)
Two to four years related experience and/or training; or equivalent combination of education and experience.
Knowledge of word processing software, spreadsheet software, internet software