Customer Solution Center Service Representative III

Job Summary

Under the general direction of leadership and management in the Customer Solution Center, Call Center, the Customer Solution Center Service Representative III handles provider inquiries and issue resolution of Level One (1) inquiries, this includes but not limited to, general inquiries on claims processing and status and eligibility verification. In addition, this position will provide support as-needed to members on in-bound calls as part of the larger role of "one-stop shop" service in the Customer Solution Center. Acts as a  Subject Matter Expert, serves as a resource and mentor for other staff.

Duties

Assist providers in response to telephonic and electronic inquiries and concerns on all products and paid/unpaid claims. Ensure that accurate information is being given to the provider in a timely manner and with the highest level of customer service. Handle Level One (1) provider inquiries this includes (but not limited to): general inquiries on claims processing, payment status and appeal and eligibility status verification. Document the interaction with the provider, including any resolution or escalation steps in the system of record for each call. Provide detailed information for each call including: Caller information; Information related to request/issue; Resolution information or escalation steps.  Escalate Level Two (2) provider concerns to the Claims Department for resolution (e.g. Provider Disputes, incorrectly paid claims, payment check status, Explanation of Benefits (EOB) requests. (50%)

Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable  meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.(20%)

Support the Call Center in meeting State regulatory requirements by handling member-related inbound calls. (10%)

Perform special projects and ad-hoc assignments when necessary. (10%)

Perform other duties as assigned. (10%)

Duties Continued

Education Required

Education Preferred

Experience

Required:
At least 2 years of experience in customer service in a high-call-volume healthcare customer service call center, including a minimum of 2 years of general claims inquiry or managed care specialty line of business experience.
 
Customer service training in a healthcare environment.

Data entry experience with the ability to type a professional minimum of 35 wpm.

Skills

Required:
Working knowledge of Microsoft Office Suite (e.g. Word, Excel, PowerPoint, Outlook).

Excellent communication skills (written and verbal).

Ability to navigate multiple programs/databases while assisting each caller.

Proficient knowledge in healthcare product lines, medical terminology and claims processes.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Preferred:
Technical training/certificate in a technical or business school (e.g. medical billing, medical terminology, medical coding, healthcare).

Physical Requirements

Additional Information